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OF 

THE  UNIVERSITY 
OF  CALIFORNIA 

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1114  W  HARRISON  ST.  CHICAGO 


NORMAL  FUNDUS, 
grange  Gofer.) 


MANUAL 


CLINICAL  OPHTHALMOLOGY 


BY 

HOWARD  F.   HANSELL,  M.D., 

LECTURER    ON    OPHTHALMOLOGY    IN  THE    JEFFERSON    MEDICAL  COLLEGE;    CHIEF   CLINICAL 

ASSISTANT    IN    EYE    DEPARTMENT,   JEFFERSON    MEDICAL    COLLEGE    HOSPITAL; 

MEMBER    OF    AMERICAN    OPHTHALMOLOGICAL    SOCIETY;      FELLOW 

OF  THE  COLLEGE  OF   PHYSICIANS,    PHILADELPHIA,   ETC., 


AND 


JAMES    H.    BELL,    M.D., 

LATELY    DEMONSTRATOR    OF    ANATOMY    IN    JEFFERSON     MEDICAL    COLLEGE  ;      MEMBER    OP 

OPHTHALMOLOGICAL    STAFF,    JEFFERSON    MEDICAL    COLLEGE     HOSPITAL; 

OPHTHALMIC   SURGEON   TO   SOUTHWESTERN    HOSPITAL 

AND    DISPENSARY,    ETC. 


WITH    120    ILLUSTRATIONS. 


PHILADELPHIA: 
P.    BLAKISTON,    SON    &    CO., 

1012    WALNUT    STREET. 
1892. 


COPYRIGHT,  1892,  BY  P.  BLAKISTON,  SON  &  Co. 


PTCM  or  WM.  F.  Fru.  *  Co. 
1220-24  SANSOM  ST. 


TO 

WILLIAM  THOMSON,  M.  D., 

PROFESSOR   OF   OPHTHALMOLOGY,   JEFFERSON   MEDICAL   COLLEGE, 

AS   A    DISTINGUISHED    REPRESENTATIVE   OF   THE   SCIENCE, 


IN   RECOGNITION   OF   HIS   FRIENDSHIP, 

THIS  VOLUME  IS  INSCRIBED 
WITH    THE   SINCERE    RESPECT   AND    ESTEEM    OF 

THE  AUTHORS. 


PREFACE, 


It  has  been  our  purpose  in  the  following  pages  to  place 
before  the  undergraduate  and  general  practitioner  of  medi- 
cine, a  brief  review  of  the  anatomy,  physiology,  refraction, 
and  common  diseases  of  the  eye.  No  attempt  has  been 
made  to  treat  the  subjects  exhaustively.  Simplicity  and 
brevity  of  statement  have  not  been  sacrificed  to  the  mere 
attractiveness  of  literary  finish.  We  have,  in  a  word, 
endeavored  in  good  faith,  to  make  the  volume  conform  to 
the  purpose  for  which  it  was  written,  by  giving  it  the 
character,  directness,  and  practicability  of  clinical  teaching 
and  practice. 

We  have  been  equally  and  jointly  engaged  in  the  com- 
position and  arrangement  of  each  and  every  chapter,  and 
for  all  portions  of  the  book  we  are,  therefore,  equally  and 
jointly  responsible. 


TABLE  OF  CONTENTS. 


PART  I. 

PAGE 

GENERAL  CONSIDERATIONS,  STRUCTURAL  AND  PHYSIOLOGICAL. 

Sclera.  —  Cornea.  —  Choroid.  —  Ciliary  Body.  —  Ciliary  Processes. 
— Iris— Retina.  —  Anterior  Chamber.  —  Posterior  Chamber. — 
,  Vitreous  Chamber. — Hyaloid  Membrane.  —  Ligament  of  the 
Lens. — Crystalline  Lens. —  Anterior  Capsule. —  Optic  Nerve. — 
Optic  Tracts. — Chiasm. — Nerves. — Arteries  and  Veins. — Lym- 
phatics.— Muscles. — Optic  Axis. — Conjunctiva. — Lacrymal  Ap- 
paratus. —  Accommodation.  —  Relative  Accommodation. — The 
Metre  Angle. — Test  Cards  and  Lenses. — Field  of  Vision. — 
The  Perimeter. — Colors. — Color-Sense. — Color-Blindness,  ....  9-41 


PART  II. 

PHYSIOLOGICAL  OPTICS. 

Reflection. — Refraction  by  Plane,  Prismatic,  Spherical,  and  Cylin- 
drical Lenses. — The  Dioptric  System. — The  Ophthalmoscope. — 
Formation  of  Images  by  Direct  and  Indirect  Methods, 42-52 

PART  III. 
REFRACTION. 

Normal  Refraction.  —  Emmetropia.  —  Hypermetropia.  —  Myopia. — 
Astigmatism.  —  The  Refraction  Ophthalmoscope.  —  Direct 
Examination. — Indirect  Examination. — Determination  of  Refrac- 
tion by  the  Ophthalmoscope.  —  Retinosocpy  by  the  Plane 

Mirror. — Presbyopia. — Mydriatics, 53"77 

vii 


VI11  TABLE   OF   CONTENTS. 

PART  IV. 

PACK 

THE  OCULAR  MUSCLES. 

Paralysis  of. — Ophthalmoplegia  Externa  and  Interna. — Nystagmus. 
— Orthophoria. — Hetcrophoria. — Orthotropia. — Heterotropia. — 
The  Tests  for  Muscular  Strength — Symptoms  of  Heterophoria. 
— Diagnosis  of  Heterophoria. — Treatment  of  Heterophoria. — 
Strabismus, 78-9,' 

PART  V. 

DISEASES  OF  THE  CONJUNCTIVA. 

Hyperaemia. —  Conjunctivitis:  Acute  Catarrhal,  Chronic  Catarrbal, 
Vernal,  Follicular,  Granular,  Blennorrhoeal,  Phlyctenular, 
Croupous,  Diphtheritic. —  Xerosis. — Pterygium.—  Tumors,  .  .  .  92-105 

PART  VI. 
DISEASES  OF  THE  LIDS. 

Coloboma. — Epicanthus. — Congenital  Ptosis. — Traumatism. — Phleg- 
mon. —  Hordeolum.  — -Blepharitis.  —  Marginal  Blepharitis.  — 
Erythema. — CEdema. —  Emphysema. —  Rodent  Ulcer. —  Epithe- 
lioma.— Lupus. — Xanthelasma. — Chancre. — Chalazion. —  Ecchy- 
mosis. —  Milium. —  Trichiasis. — Alopecia. — Pediculus  Pubis. — 
Entropion. — Ectropion. — Blepharospasm. — Blepharophimosis. — 
Acquired  Ptosis. — Symblepharon. — Ankyloblepbaron. 

DISEASES  OF  THE  LACRYMAL  APPARATUS. 

Hypertrophy  of  Lacrymal  Gland. — Abscess  of  Lacrymal  Gland. — 
Fistula  of  Lacrymal  Gland.  —  Malposition  of  Puncta  Lacry- 
malia. — Stricture  of  the  Nasal  Duct. — -Blennorrhcea  of  Lacrymal 
Sac. — Dacryocystitis. — Abscess  of  Lacrymal  Sac. — Fistule  of 
Lacrymal  Sac, Io6-I2l 

PART  VII. 

DISEASES  OF  THE  CORNEA. 

Phlyctenular  Keratitis.  —  Herpes. —  Pannus.  —  Ophthalmic  I lerpes 
Zoster. —  Resorption  Ulcer. — Serpiginous  Ulcer — Interstitial  or 
Parenchymatous  Keratitis. —  Abscess. —  Neuro- Paralytic  Kera- 
titis. —  Necrosis.  —  Arcus  Senilis. — Opacities.  —  Conical  Cor- 
nea.— Staphyloma. — Tumors. 

DISEASES  OF  THE  SCLERA. 
Scleritis. — Anterior  Staphyloma. — Posterior  Staphyloma 122-135 


TABLE    OF    CONTENTS.  IX 

PART  VIII. 

PAGE 

DISEASES  OF  THE  CRYSTALLINE  KENS  AND  LENS  CAPSULE. 
Cataract:   Central,  Anterior  Polar,  Posterior  Polar,  Zonular,  Total, 
Senile,  Traumatic. — Dislocation  of  the  Lens. — Apliakia. — Depo- 
sition on  Anterior  and  Posterior  Surfaces  of  Capsule. — Wounds. — 
Secondary  Cataract, 136-146 

PART  IX. 

DISEASES  OF  THE  UVEAL  TRACT. 

The  Iris. — Congenital  Anomalies. —  Aniridia. — Coloboma. — Persis- 
tent Pupillary  Membrane.  —  Polycoria.  —  Albinism.  —  Hyper- 
semia. — Plastic  Iritis. — Serous  Iritis. —  Parenchymatous  or  Sup- 
purative  Iritis. —  Mydriasis.  —  Myosis.  —  Argyll  -  Robertson 
Pupil.  —  Hyphsemia. —  Detachment. —  Tumors. —  The  Ciliary 
Body. — Cyclitis. — Sympathetic  Inflammation. — Chronic  Cyclitis. 

DISEASES  OF  THE  CHOROID. 
Choroiditis.  —  Disseminated. —  Areolar. —  Central.  — Central    Senile 

Atrophy. — Central  Guttate, 147-162 

PART  X. 

DISEASES  OF  THE  VITREOUS. 
Hyalitis. — Muscae   Volitantes. — Synchisis. — Synchisis  Scintillans. — 

Hyaloid  Artery. —  Foreign  Bodies, 163-165 

PART  XL 
GLAUCOMA. 
Simple,  Chronic    Inflammatory,  Acute  Inflammatory,  Fulminating, 

Secondary. — Glaucomatous  Degeneration 166-171 

PART  XII. 

DISEASES  OF  THE  RETINA. 

Hyperremia.  —  Anaemia.  —  Embolism  Central  Retinal  Artery.  — 
Hemorrhage.  —  Opaque  Nerve  Fibres.  —  Hemorrhagic  Reti- 
niti?.—  Albuminuric  Retinitis. —  Diffused  Chronic  Retinitis. — 
Retinitis  Pigmentosa.  —  Detachment.  —  Acute  Central  Reti- 
nitis.— Hyperaesthesia. — Anaesthesia. — Glioma 172-184 


X  TABLE    OF    CONTENTS. 

PART  XIII. 

PAD! 

DISEASES  OK  THE  Optic  NERVK. 
Acute   Neuritis.  —  Papillitis. —  Retro-  Bulbar   Neuritis. —  Atrophy. — 

Tobacco  and  Alcohol  Amblyopia.  —  Hemianopsia, i<\=;    !')_• 

PART   XIV. 

* 

DISEASES  OF  THE  ORBITAL  CAVITY. 
Periostitis. — Phlegmon. — Tumors. — Exophthalmus. — Enophthalmus.  193-194 

PART  XV. 
OPERATIONS. 

Cataract  Extraction  with  Iridectomy. — Cataract  Extraction  without 
Iridectomy. — Discission. — Iridectomy. —  Iritomy. —  Paracentesis 
Cornea.  —  Sc-emisch  Incision.  —  Conical  Cornea. —  Staphyloma 
Cornea  and  Sclera. — Tattooing. — Foreign  Bodies  in  Conjunctiva, 
in  Cornea,  in  Anterior  Chamber,  in  Lens,  in  Vitreous  Cham- 
ber.— Tenotomy.  —  Graded  or  Partial  Tenotomy. — Advancement 
of  Tendon. — Enucleation. — Symblepharon. —  Ankyloblepharon. 
—  Canthotomy.  —  Canthoplasty.  —  Tarsorraphy.  —  Excision  of 
Cilize. — Entropion. — Ectropion. —  Chalazion. — Ptosis. — Stricture 
of  Lacrymal  Duct. — Epithelioma. — Ulcer. — Naevi. — Warty  Kx- 
crescences, 195-223 


LIST  OF  ILLUSTRATIONS.* 


KIG.  PAGE 

1.  Vertical  Section  of  the  Cornea, II 

2.  Vertical  Section  of  the  Choroid, 12 

3.  Antero- Posterior  Section  of  the  Cornea  and  Sclerotic, 13 

4.  Anterior  Quadrant  of  a  Horizontal  Section  of  the  Eyeball,  Cornea, 

and  Lens, 15 

5.  Vertical  Section  of  Human  Retina,   .    .        16 

6.  Section  of  the  Fovea  Centralis, 17 

7.  Fibres  of  the  Lens, 19 

8.  Diagram  of  the  Decussation  of  the  Optic  Tracts, 19 

9.  Horizontal  Section  of  the  Entrance  of  the  Optic  Nerve  and  the  Coats 

of  the  Eye, 20 

10.  Diagram  of  the  Blood-vessels  of  the  Eye, 23 

n.  Lateral  View  of  the  Muscles  of  the  Eyeball,    .    .    .    . 26 

12.  Vertical  Section  through  the  Upper  Eyelid, 28 

13.  Lacrymal    Apparatus 30 

14.  Scheme  of  the  Accommodation  for  Near  and  Distant  Objects,    ...  32 

15.  Test  Case 35 

16.  McHardy's  Perimeter, 38 

17.  Spectrum  Obtained  by  Means  of  a  Prism, 40 

1 8.  Refraction  by  Medium  with  Parallel  Sides, 43 

19.  Refraction  by  a  Prism, 44 

20.  Juxtaposed  Prisms, 45 

21.  Different  Forms  of  Spherical  Lenses, 45 

22.  Refraction  of  Parallel,  Diverging  and  Converging  Rays  by  Convex 

Lens, 46 

23.  Refraction  of  Parallel  Rays  by  Concave  Lens, 48 

24.  Cylinders,      48 

25.  Direct  Examination  by  Ophthalmoscope, 51 

*  None  of  the  illustrations  are  original ;  they  have  been  taken  from  the  works  of  Meyer, 
Netileship,  Landois  and  Stirling,  Littell,  Harlan,  and  Jaeger.  E.  A.  Yarnall  &  Co.  have 
furnished  the  cuts  for  the  instruments,  and  J.  L.  Borsch  &  Co.  for  lenses  and  for  an  astig- 
matic chart. 

xi 


Xll  LIST    OF    ILLUSTRATIONS. 

FIG.  PAGE 

26.  Indirect  Examination  by  Ophthalmoscope, 52 

27.  Condition  of  Refraction   in  the  Normal   Passive   Eye   and   During 

Accommodation, 53 

28.  Condition  of  Refraction  in  the  Normal  Eye  During  Accommodation,  54 

29.  Hypermetropic  Eye 55 

30.  Myopic  Eye, 57 

31.  Action  of  an  Astigmatic  Surface  on  a  Cone  of  Light, 60 

32.  Astigmatic  Clock  for  Testing  Astigmatism 62 

33.  Morton's  Ophthalmoscope, 64 

34.  The  Entrance  of  the  Optic  Nerve  with  the  Adjacent  Parts  of  the 

Fundus  of  the  Normal  Eye, 65 

35.  Illustration  of  Retinoscopy  by  the  Plane  Mirror, 69 

36.  Diagrams  of  Range  of  Accommodation  in  E.,  H.,  and  M.,  ....    74 

37.  Scheme  of  the  Action  of  the  Ocular  Muscles, 79 

38.  Pathological  Convergence :   Homonymous  Diplopia, 80 

39.  Pathological  Divergence  :  Heteronymous  Diplopia, 8l 

40.  Conjunctival  and  Subconjunctival  Injection, 93 

41.  Granular  Conjunctivitis, 96 

42.  Pannus  Affecting  Upper  Half  of  Cornea, 98 

43.  Phlyctenular  Ophthalmia,  Conjunctival  Form, 102 

44.  Pterygium,     . 105 

45.  Epicanthus, 106 

46.  Ptosis, 107 

47.  Meibomian  Cyst.     Lid  Forceps, 1 1 1 

48.  Trichiasis, 1 1 3 

49.  Distichiasis, 113 

50.  Entropion  of  Lower  Lids, 114 

51.  Ectropion  of  Lower  Lid 115 

52.  Symblepharon, 117 

53.  Ankyloblepharon, 117 

54.  Lacrymal  Gland 118 

55.  Fistule  of  Lacrymal  Sac, 120 

56.  Phlyctenular  Ulcer 123 

57.  Perforating  Ulcer  of  the  Cornea  ;  Adhesion  of  Iris, 126 

58.  Onxy  and  Hypopyon, 126 

59.  Acute  Serpiginous  Ulcer  of  the  Cornea 127 

60.  Interstitial  Keratitis, 128 

61.  Partial  Staphyloma  of  the  Cornea, 130 

62.  Partial  Staphyloma  of  the  Cornea  and  Iris, 130 

63.  Total  Staphyloma  of  the  Cornea  and  Iris, 131 


LIST    OF    ILLUSTRATIONS.  xiii 

FIG.  PAGE 

64.  Staphyloma  of  Sclera 133 

65.  Post-Staphyloma, „ 134 

66.  Posterior  Polar  Cataract, 136 

Illustrations  of  Cataract, 139  and  140 

67.  Posterior  Synechia, 148 

68.  Serous  Iritis, 151 

69.  Atrophy  after  Syphilitic  Choroiditis, 159 

70.  Central  Choroiditis, 159 

71.  Central  Guttate  Senile  Choroiditis, 160 

72.  Glaucomatous  Excavation  of  the  Optic  Nerve  (Vertical  Section),      .  168 

73.  Glaucomatous  Excavation  (Ophthalmoscopic  View), 168 

74.  Embolism  of  the  Central  Artery  of  the  Retina, 173 

75.  RetinitisxAlbuminurica, 177 

76.  Retinitis  Pigmentosa, 180 

77.  Ophthalmoscopic  Appearance  of  Detached  Retina, 181 

78.  Optic  Neuritis,      186 

79.  Atrophic  Excavation, 189 

80.  Lid  Speculum, 196 

81.  Fixation  Forceps, 196 

82.  Graefe  Cataract  Knife, 196 

83.  Iris  Forceps, 197 

84.  Iridectomy  Scissors, 197 

85.  Cystotome 198 

86.  Expulsion  of  the  Cataract, 198 

87.  Graefe  Cataract  Spoon  and  Cystotome, 198 

88.  Wire  Loop, 200 

89.  Lens  Extractor, 200 

90.  Discission, 201 

91.  Soft  Cataract  Needle, 202 

92.  Escape  of  Lens  Masses  from  Anterior  Chamber, 202 

93.  Linear  Incision  at  the  Superior  Margin  of  the  Cornea, 203 

94.  Iridectomy  Knife, 203 

95.  Artificial  Pupil  as  seen  in  Anterior  Chamber  after  Iridectomy,  .    .    .  204 

96.  Iridotomy    Knife, 204 

97.  De  Wecker's  Iritomy  Scissors, 205 

98.  Paracentesis  Knife, 205 

99.  Needles  in  Position  (Ant.  Staphyloma), 206 

100.  Excision  of  the  Staphyloma, 207 

101.  Appearance  of  the  Stump  after  Excision  of  the  Staphyloma,     .    .    .  207 

102.  Tattooing  Needle 208 


XIV  LIST    OF    ILLUSTRATIONS. 

FIG.  PACK 

103.  Spud 209 

104.  Incision  of  the  Conjunctiva 210 

105.  Section  of  the  Tendinous  Insertion, 210 

106.  Strabismus  Hook 210 

107.  Conjunctival  Scissors, 211 

108.  Enucleation  Scissors, 214 

109.  Operation  for  Symblepharon, 215 

no.  Aril's  Method 215 

111.  Canthoplasty, 216 

112.  Tarsorrhaphia, 217 

113.  Horn  Plate, 217 

114.  Lid  Forceps, 217 

115.  Operation  for  Distichiasis, .'....  218 

1 1 6.  Operation  for  Ectropion, 220 

117.  Operation  for  Ectropion, 220 

118.  Canaliculus  Knife, 221 

119.  Probing  the  Nasal  Duct, 222 

1 20.  Bowman's  Probes, 222 


ERRATUM. 


Page  77,  line  9.     Hydrobromate   should  read  Hydrochlorate. 


A  MANUAL 


CLINICAL    OPHTHALMOLOGY, 


PART  I. 

GENERAL   CONSIDERATIONS— STRUCTURAL 
AND    PHYSIOLOGICAL. 

The  human  eyeball  is  spheroidal  in  shape ;  24  mm.  in  its 
antero-posterior,  23  mm.  in  its  transverse,  and  23  mm.  in 
its  vertical  axis.  Three  tunics  are  commonly  described, 
namely,  an  inner  percipient  coat,  the  retina,  a  middle  vas- 
cular coat,  the  choroid,  and  an  outer  and  protecting  coat, 
the  sclera,  with  its  transparent  continuation  in  front,  the 
cornea. 

The  sclera  is  a  bluish-white,  opaque,  dense,  resisting 
membrane,  composed  of  closely  interlacing  connective  tis- 
sue fibres  with  a  sparse  intermingling  of  fine  elastic  tissue. 
Among  the  fibres  are  numerous  lymph  channels  communi- 
cating with  the  lymph  system  of  the  cornea,  the  underlying 
peri-choroid,  and  with  the  overlying  capsule  of  Tenon.  A 
few  small  blood-vessels  and  nerves  are  distributed  through- 
out its  substance.  Slightly  below  and  four  mm.  to  the  nasal 
side  of  the  posterior  extremity  of  the  horizontal  axis  of  the 

9 


IO  A    MANUAL   OF   CLINICAL   OPHTHALMOLOGY. 

ball  is  an  incomplete  opening,  \y*  mm.  in  diameter,  the 
sclerotic  foramen,  over  which  is  stretched  a  white  fibrous 
veil,  the  lamina  cribrosa,  pierced  by  the  optic  nerve,  central 
artery  and  vein  of  the  retina.  At  the  margin  of  this  fora- 
men the  sclera  is  one  mm.  thick,  being  reinforced  by  a 
deflection  of  the  outer  sheath  of  the  optic  nerve,  and  gradu- 
ally thins  off  anteriorly,  to  be  again  reinforced  six  to  eight 
mm.  back  of  the  limbus  cornea,  corneo-sclcral  margin ,  by  the 
expanding  tendons  of  the  recti  muscles.  It  is  marked  just 
at  its  corneal  border  by  a  slight  depression,  the  su/cus  schra. 
The  sclera  is  pierced  ten  to  twelve  mm.  from  the  foramen 
sclera  by  the  posterior  ciliary  vessels  and  nerves ;  again 
midway  between  the  optic  nerve  entrance  and  cornea,  by 
four  or  five  large  veins,  venae  vorticosae,  which  empty  into 
the  ophthalmic  vein.  It  is  again  perforated  two  mm.  from 
the  limbus  cornea  by  the  anterior  ciliary  vessels,  four  or 
five  in  number. 

The  cornea  is  the  anterior,  smaller  and  transparent  por- 
tion of  the  external  tunic,  measuring  eleven  mm.  vertically, 
twelve  mm.  horizontally,  and  one  mm.  in  thickness  at  its 
apex.  The  layers  may  be  multiplied  indefinitely  by  resort- 
ing to  useless  and  confusing  subdivision ;  three  are  here 
given.  The  anterior  layer  consists  of  columnar  epithelium 
continuous  with  the  epithelium  of  the  conjunctiva,  and  a 
homogeneous  elastic,  basement  membrane  (Bowman's).  The 
second  or  middle  layer  composes  the  tissue  proper  of  the 
cornea,  and  is  formed  by  sixty  or  more  laminae  of  fibrous 
tissue,  containing,  in  great  number,  irregularly  placed 
lymph  spaces,  in  which  lie  the  corneal  cells,  connected 
with  each  other  in  all  directions  by  canaliculi.  The  poste- 
rior layer  consists  of  a  homogeneous  basement  membrane 
(Descemet's),  on  which  is  a  single  layer  of  hexagonal  cells 
continuous  with  that  on  the  anterior  surface  of  the  iris. 


GENERAL    CONSIDERATIONS. 


II 


In  health  the  cornea  is  devoid  of  blood-vessels,  except  at 
its  periphery,  and  contains  under  Bowman's  membrane  a 
few  terminal  branches  of  the  ciliary  nerves.  There  is  ana- 
tomically no  distinct  line  of  union  between  the  sclera  and 
cornea,  but  the  former  slightly  overlaps  the  latter  on  its 
anterior  aspect,  and  beneath  this  shelving  border  of  sclera, 
in  clear  cornea,  lies  the  canal  of  Schlemm,  which  is  con- 

FIG.  i. 


•  ••:  .•  •..'.— :->-^       --'••>>••—  ti:"-x--v /•-••.•:/•»        •..•:-••••• 


VERTICAL  SECTION  OF  THE  CORNEA,  STAINED  WITH  GOLD  CHLORIDE. 

n.  Nerve-fibrils,     a.  Perforating  branch,     r.  Nucleus.    /,  b.  Inter-epithelial  termination  of 
fibrils,     s.  Anterior  elastic  laminae. 


nected  with  the  angle   of  the   anterior    chamber   by  the 
spaces  of  Fontana. 

The  choroid  is  the  vascular  and  pigmentary  coat,  extend- 
ing posteriorly  from  fo&  foramen  opticus  choroidea,  through 
which  the  optic  nerve  passes,  and  anteriorly  to  the  ciliary 
region.  Its  outer  surface  lines  the  sclera  from  which  it  is 
separated  by  a  double  layer  of  serous  membrane,  supra- 
ckoroidal lymph  space,  and  its  inner  surface  is  attached  to  the 
basal  membrane  of  the  pigment  coat  of  the  retina  as  far  for- 
ward as  the  ora  serrata.  The  choroid  may  be  divided  into 


12 


A    MANUAL   OF    CLINICAL   OPHTHALMOLOGY. 


two  layers :  an  outer,  containing  relatively  larger  vessels  and 
more  pigment,  and  an  inner,  containing  capillary  vessels  and 
less  pigment.  The  most  conspicuous  vessels  of  the  external 
layer  are  the  veins,  which,  converging,  form  the  vena  vorti- 
cosce.  The  capillary  vessels  of  the  inner  layer  are  derived 

FIG.  2. 


VERTICAL  SECTION  OF  THE  CHOROID  AND  A  PART  OF  THE  SCLEROTIC. 

i.  Sclerotic.  2.  Lamina  suprachoroidea.  3.  Layer  of  large  vessels.  4.  Limiting  layer.  5. 
Chorio-capillaris.  6.  Hyaline  membrane.  7.  Pigment  epithelium,  g.  Large  blood- 
vessels. /.  Pigment  cells,  c.  Sections  of  capillaries. 


mainly  from  the  short  ciliary  arteries.  The  pigment,  con- 
sisting of  hexagonal  cells  filled  with  dark-brown  granules, 
is  scattered  throughout  both  layers,  occupying  the  meshes 
between  the  vessels  in  quantity  and  density  sufficient  to 
absorb  light. 

The  ciliary  body  comprises  the  ciliary  muscle  and  pro- 


FIG.  3. 


ANTERO-POSTERIOR  SECTION  OF  THE  CORNEA  WITH  THE  SCLEROTIC. 

a.  Anterior  corneal  epithelium,  b.  Bowman's  lamina,  c.  Corneal  corpuscles.  /.  Corneal 
lamellae  (the  whole  thickness  lying  between  b  and  d  is  the  substantia  propria  cornea). 
d.  Descemet's  membrane,  e.  Its  epithelium,  f.  Junction  of  cornea  with  the  sclerotic. 
^.  Limbus  conjunctivae.  //.  Conjunctiva  ;  canal  of  Schlemm.  k  Leber's  venous  plexus 
(is  regarded  by  Leber  as  belonging  to  i).  m,  m.  Meshes  in  the  tissue  of  the  ligamentum 
iridis  pectinatum.  n.  Attachment  of  the  iris.  o.  Longitudinal,  /,  circular  (divided 
transversely)  bundles  of  fibres  of  the  ciliary  muscle,  u.  Transverse  section  of  a  ciliary 
artery,  v.  Epithelium  of  the  iris  (a  continuation  of  that  on  the  posterior  surface  of  the 
cornea),  iv.  Substance  of  the  iris.  x.  Pigment  of  the  iris.  z.  A  ciliary  process. 

13 


14  A    MANUAL   OF   CLINICAL   OPHTHALMOLOGY. 

cesses,  and  the  space  they  occupy,  together  with  the  cor- 
responding circular  strip  of  sclera,  is  the  ciliary  region. 
The  ciliary  muscle,  attached  anteriorly  to  the  ligaincntuni 
pectinatum  iridis  and  lost  posteriorly  in  the  choroid  oppo- 
site to  the  ora  serrata,  consists  of  radiating  and  circular 
bundles  of  unstriped  muscular  fibre,  containing  the  arterial 
circle,  the  circulus  ciliaris. 

The  ciliary  processes  consist  of  an  anterior  prolongation 
of  the  pigment  stroma  and  blood-vessels  of  the  choroid, 
with  a  reduplication  into  sixty  or  seventy  folds,  resting  on 
the  anterior  periphery  of  the  vitreous. 

The  Zone  of  Zinn  is  the  pigmented  indentations  made 
by  the  ciliary  processes  in  the  hyaloid  membrane. 

The  Iris  is  a  circular  framework  of  elastic  and  non-striped 
muscular  fibres,  lined  anteriorly  by  flat  epithelium,  con- 
tinuous with  the  membrane  of  Descemet,  and  posteriorly 
by  the  uvea,  or  pigment  coat,  continued  forward  from  the 
ciliary  processes.  It  is  suspended  in  the  aqueous  humor 
2l/t  mm.  behind  the  cornea,  and  in  front  of  the  lens  and 
ciliary  processes.  By  the  ciliary  ligament  (ligamentum 
pectinatum  iridis)  its  circumference  is  attached  to  the  limbus 
cornea;.  It  is  perforated  by  a  nearly  circular  hole,  the 
pupil,  the  margin  of  which,  the  pupillary  border,  lies  in 
contact  with  the  anterior  capsule  of  the  lens.  The  sphincter 
pupillce  is  a  circular  band  of  muscular  fibres  surrounding  the 
pupil.  The  dilator  iridis  is,  according  to  late  authorities, 
not  a  muscle,  but  a  fibre-elastic  tissue.  The  iris  has  two 
circles  of  anastomosing  vessels,  the  larger  surrounding  the 
ciliary  and  the  smaller  the  pupillary  border,  branches  of  the 
anterior  and  long  ciliary.  Filaments  from  the  lenticular 
(ophthalmic)  ganglion,  containing  motor  fibres  from  3rd, 
sensitive  from  ist  division  of  5th,  and  sympathetic  filaments 
from  the  carotid  plexus,  furnish  its  nerve  supply. 


GENERAL    CONSIDERATIONS. 


The  Retina,  or  nervous,  tunic,  is  composed  of  three  main 
layers  :  the  inner,  fibre  and  nerve-cell,  the  middle,  granular, 
and  the  internal,  or  layer  of  rods,  cones  and  pigment.  The 


FIG.  4. 


ANTERIOR  QUADRANT  OF  A  HORIZONTAL  SECTION  OF  THE 
EYEBALL,  CORNEA,  AND  LENS. 


Substantia  propria  of  the  cornea,  b.  Bowman's  elastic  membrane,  c.  Anterior 
corneal  epithelium,  d.  Descemet's  membrane,  e.  Its  epithelium,  f.  Conjunctiva. 
g.  Sclerotic,  h.  Iris.  i.  Sphincter  iridis.  j,  Ligamentum  pectinatum  iridis,  with  the 
adjoining  vacuolated  tissue,  k.  Canal  of  Schlemm.  /.  Longitudinal,  m,  circular  mus- 
cular fibres  of  the  ciliary  muscle,  n.  Ciliary  process,  o.  Ciliary  part  of  the  retina. 
q.  Canal  of  Petit,  with  Z,  Zonule  of  Zinn,  in  front  of  it,  and  /,  the  posterior  layer  of  the 
hyaloid  membrane,  r.  Anterior,  v,  posterior  part  of  the  capsule  of  the  lens.  t.  Cho- 
roid.4  u.  Perichoroidal  space.  T.  Pigment  epithelium  of  the  iris.  x.  Margin  of  the 
lens. 


first  or  inner  layer  consists  of  the  expanded  intra-ocular  ex- 
tremity of  the  optic  nerve  fibres,  stripped  of  their  medullary 
sheaths,  with  numerous  multipolar  cells ;  the  second,  of 


i6 


A    MANUAL   OF    CLINICAL   OPHTHALMOLOGY. 


granular  and  granulated  cells,  arranged  in  four  strata,  con- 
necting the  inner  and  outer ;  the  third  is  the  sentient  layer 
proper,  and  is  composed  of  elongated  nerve-cells,  the  rods 


FIG.  5. 


VERTICAL  SECTION  OF  HUMAN  RETINA. 

a.  Rods  and  cones.    l>.  Ext.  and,  /,  int.  limit,  memb.  c.  Ext.  and,/,  int.  nucl. layers,   e.  Ext. 
and,  g,  int.  gran,  layers,   h.  Blood-vessels  and  nerve  cells.    /.  Nerve-fibres. 

and  somewhat  shorter  cones,  inserted  into  the  pigment 
layer.  Each  layer  is  transparent,  with  the  exception  of 
the  pigment  coat.  The  retina  is  about  .25  mm.  in  thick- 
ness, covers  the  under  surface  of  the  choroid  from  the 


GENERAL    CONSIDERATIONS.  \"J 

foramen  choroidea  to  the  ora  serrata,  or  notched  and  den- 
tated  anterior  margin  of  the  retina,  allowing  the  lining  mem- 
brane of  vitreous  to  come  into  immediate  contact  with  the 
choroid  for  the  space  of  a  few  mm.  behind  the  ciliary  body. 
The  macula  lutea  is  a  yellowish  spot,  as  seen  by  the  ophthal- 
moscope, irregular  in  shape,  but  usually  circular,  0.5  mm. 
in  diameter,  and  lies  slightly  to  the  temporal  side  of  the 
posterior  end  of  the  optic  axis.  In  the  centre  of  the  macula 

FIG.  6. 


SECTION  OF  THE  FOVEA  CENTRALIS. 

a.  Cones,     b  and  g.  Int.  and  ext.  limit,  memb.     c.  Ext.  and  e,  nuclear  layer,     d.  Fibres. 
f.  Nerve-cells. 

is  the  fovea  centralis  (Fig.  6),  .2  mm.  in  diameter,  charac- 
terized by  an  absence  of  all  the  layers  of  the  retina,  except- 
ing modified  rods  and  cones.  The  central  artery  and  vein 
of  the  retina  pass  through  the  poms  opticus,  a  comparatively 
large  aperture  in  the  lamina  cribrosa,  and,  dividing,  ver- 
tically, into  large  and,  horizontally,  small  vessels,  are 
distributed  in  the  fibre  layer  of  the  retina,  anastomosing  at 
.the  ora  serrata  with  the  choroidal  and,  at  the  optic  nerve 
entrance,  with  the  short  ciliary  vessels. 


l8  A    MANUAL   OF    CLINICAL   OPHTHALMOLOGY. 

The  anterior  chamber  is  an  angular  space,  bounded  in 
front  by  the  posterior  surface  of  the  cornea,  at  its  angle  by 
the  ligamentum  pectinatum  iridis,  and  behind  by  the 
anterior  surface  of  the  iris.  It  secretes  and  contains  the 
aqueous  humor,  a  feebly  saline,  transparent  fluid. 

The  smaller  posterior  chamber  is  bounded  in  front  by  the 
posterior  surface  of  the  iris,  and  behind  by  the  ciliary  pro- 
cesses, suspensory  ligament  of  the  lens  and  lens,  and  con- 
tains aqueous  humor.  The  anterior  and  posterior  chambers 
are  in  free  communication  through  the  pupil. 

The  vitreous  chamber  is  bounded  by  the  retina,  ciliary 
processes  and  lens,  and  contains  the  vitreous  humor,  a 
transparent,  jelly-like  substance,  supported  by  numerous 
septa. 

The  Hyaloid  membrane  is  a  fine,  transparent  layer  of  con- 
nective tissue,  enclosing  the  vitreous,  and  forms,  by  division 
anteriorly  at  the  ciliary  processes,  the  suspensory  ligament 
of  the  lens.  The  canal  of  Petit  is  the  name  given  to  the 
space  between  the  layers  of  the  suspensory  ligament  at  the 
periphery  of  the  lens.  Anteriorly  the  vitreous  presents  a 
well-marked  depression,  the  hyaloid  fossa,  in  which  rests 
the  posterior  convexity  of  the  lens.  The  vitreous  is  tra- 
versed in  its  antero-posterior  axis  in  the  foetus  by  the 
canal  of  Cloquet,  containing  the  hyaloid  artery. 

The  crystalline  lens  is  a  biconvex  and  transparent  body, 
varying  in  consistence  at  different  ages,  from  8-10  mm.  in 
diameter  and  3—4  mm.  in  depth  at  its  axis.  It  is  enveloped 
in  front  by  the  capsule,  at  its  periphery  by  the  suspensory 
ligament,  and  behind  by  the  hyaloid.  Its  substance  is 
arranged  in  concentric  lamellae,  composed  of  minute  fibril- 
lae,  hexagonal  in  horizontal  section  (Fig.  7,  2).  Between 
the  lamellae  and  among  the  fibres  is  an  oil-like  material, 
Liquor  Morgagni,  which  permits  of  change  of  form  without 


GENERAL    CONSIDERATIONS.  19 

friction.  The  concentric  lamellae  are  approximated  by 
sutures,  thus  dividing  the  lens  into  sections  along  radiat- 
ing planes.  Considered  as  a  whole,  the  lens  consists  of  a 
nucleus,  the  almost  structureless  centre,  and  cortex,  the  outer 
fibrillary  and  softer  portion. 


Fie.  7. 


FIG.  8. 


FIG.  7.     FIBRES  OF  THE  LENS. 

2.  Transverse  sections  of  the  lens  fibres. 

FIG.  8.  DIAGRAM  OF  THE  DECUSSATION  OF  THE  OPTIC  TRACTS. 

T.  Semi-decussation  in  the  chiasma.  T,  Q.  Decussation  of  fibres  behind  the  ext.geniculate 
bodies  (C,  G).  a',b.  Fibres  which  do  not  decussate  in  the  chiasma.  6',a'.  Fibres  pro- 
ceeding from  the  right  eye  and  coming  together  in  the  left  hemisphere  (L,  O,  G). 
L,O,G,K.  Lesion  of  the  left  optic  tract,  producing  right  lateral  hemianopsia.  a.  Lesion 
in  the  left  hemisphere,  producing  crossed  amblyopia  (right  eye).  T.  Lesion  producing 
temporal  hemianopsia.  n,  n.  Lesion  producing  nasal  hemianopsia. 


The  anterior  capsule  is  tough  and  elastic,  and  is  lined  on 
its  posterior  surface  by  a  layer  of  hexagonal  cells,  whose 
function  it  is  to  nourish  the  fibres. 

The  fibres  of  the  optic  nerves  (Fig.  8)  arise  in  two  bands, 
the  optic  tracts,  from  the  corpora  geniculata,  corpora  quad- 


20 


A    MANUAL   OF    CLINICAL   OPHTHALMOLOGY. 


FIG.  9. 


HORIZONTAL  SECTION  OF  THE  ENTRANCE  OF  THE  OPTIC  NERVE  AND 
THE  COATS  OF  THE  EYE. 

,  Inner,  i>.  Outer,  layers  of  the  retina,  c.  Choroid.  d.  Sclerotic,  t.  Physiological  cup. 
f.  Central  artery  of  retina  in  axial  canal,  g.  Its  point  of  bifurcation,  h.  Lamina  cri- 
brosa.  /.  Outer  (dural)  sheath,  m.  Outer  (subdural}  space.  ».  Inner  (subarachnoid) 
space,  r.  Middle  (arachnoid)  sheath.  /.  Inner  (pial)  sheath.  i.  Bundles  of  nerve- 
fibres,  k.  Longitudinal  septa  of  connective-tissue. 


NERVES.  2 1 

rigemina  and  ophthalmic  ganglion,  which  are  connected  by 
radiating  fibres  with  the  cortical  centre  in  the  occipito- 
angular  region  of  the  cortex.  Each  optic  tract  winds 
obliquely  across  the  corresponding  crus  cerebri,  converges 
forward  to  meet  its  fellow  on  the  opposite  side,  forming  at 
their  intersection  the  optic  commissure,  or  chiasm.  In  the 
chiasm  is  a  partial  crossing  of  the  fibres  from  each  tract. 
The  nerves  arise  from  the  chiasm,  diverge,  and  each  passes 
through  the  optic  foramen  in  the  corresponding  lesser 
wing  of  the  sphenoid  bone.  Each  nerve  is  covered  by  pro- 
longations of  the  membranes  of  the  brain,  which  form  its 
sheaths  and  between  which  are  the  intervaginal  and  sub- 
dural  lymph-spaces.  Just  before  the  nerve  reaches  the 
lamina  cribrosa,  the  network  of  connective  tissue  extending 
across  the  foramen  sclera,  the  dura  mater  passes  over  into 
the  sclera,  the  arachnoid  and  pia  mater  are  discontinued,  the 
medullary  covering  of  the  nerve  fibres  is  dropped,  and  only 
the  axes-cylinders  pass  through  the  foramen  sclera  and 
choroidea  to  form  the  nerve-fibre  layer  of  the  retina. 
Eighteen  mm.  posterior  to  this  point,  the  ophthalmic  artery 
and  vein  pierce  the  nerve  obliquely,  and  having  reached  its 
centre,  continue  forward,  and,  passing  through  the  porus 
opticus,  are  distributed  to  the  retina. 

NERVES. 

The  eyeball  and  its  appendages  are  supplied  by  sensory 
branches  from  the  first  and  second  divisions  of  the  fifth  pair, 
motor  branches  from  the  third,  fourth,  sixth, and  seventh  pairs 
of  cranial  nerves,  and  sympathetic  filaments  from  the  carotid 
and  cervical  plexuses.  The  ciliary  ganglion,  lodged  in  the 
orbit  below  the  superior  and  to  the  median  side  of  the  ex- 
ternal rectus  behind  the  ball,  receives  sympathetic  fibres  from 
the  carotid  plexus,  sensory  from  the  first  or  ophthalmic  divi- 


22  A    MANUAL   OF   CLINICAL  OPHTHALMOLOGY. 

sion  of  fifth,  and  motor  fibres  from  the  third.  From  it  a  small 
twig  joins  the  branch  of  the  third,  supplying  the  inferior 
oblique,  and  from  three  to  six  branches,  subdividing  into 
twenty,  the  short  ciliary,  enter  the  sclera  around  the  optic 
nerve.  The  ophthalmic  division  of  the  fifth  gives  off  three 
purely  sensitive  branches  just  before  passing  through 
the  sphenoidal  fissure;  the  lacrymal,  accompanying  the 
lacrymal  artery,  runs  along  the  external  rectus  muscle  to 
the  lacrymal  gland,  supplying  it,  conjunctiva,  and  integu- 
ment of  the  upper  lid ;  the  frontal,  running  forward  above 
the  levator  palpebra?  muscle,  supplies  by  its  two  terminal 
branches  the  corrugator  supercilii,  occipito-frontalis,  orbicu- 
laris  palpebrarum,  and  the  integument  of  the  lids,  forehead, 
and  scalp  ;  the  nasal,  passing  through  the  orbit  and  giving 
off  a  twig  to  the  ophthalmic  ganglion,  as  well  as  two  or 
more  branches — the  long  ciliary  nerves, — which  perforate 
the  sclera  with  the  short  ciliary,  and  run  forward  between 
the  sclera  and  choroid  to  be  distributed  to  the  ciliary  body, 
iris,  and  cornea;  and  the  infra-troclilear  to  the  conjunctive 
and  appendages  of  the  eye. 

The  third  nerve,  motor  oculi,  supplies  the  internal,  supe- 
rior and  inferior  recti,  inferior  oblique,  levator  palpebnr, 
ciliary  muscle,  and  iris,  and  furnishes  a  motor  root  to  the 
ophthalmic  ganglion. 

The  fourth  nerve,  trochlear,  supplies  the  superior  oblique. 

The  sixth  nerve,  abducens,  supplies  the  external  rectus. 

The  seventh  nerve,  facial,  supplies  the  orbicularis  palpe- 
brarum. 

ARTERIES. 

The  ball  and  its  appendages  (Fig.  10)  are  supplied  with 
blood  directly  from  the  ophthalmic  branches  of  the 
internal  carotid,  and  indirectly  by  anastomoses  between 


ARTERIES. 


its   terminal    branches   and    similar   branches   of  the   ex- 
ternal carotid. 

The  lacrymal  artery  supplies  the  lacrymal  gland,  upper 


FIG.  10. 


DIAGRAM  OF  THE  BLOOD-VESSELS  OF  THE  EYE.     {Horizontal  view ;  veins 
black,  arteries  light,  with  a  double  contour.') 

aa.  Short  posterior  ciliary,  t.  Long  posterior  ciliary,  cc'.  Anterior  ciliary  artery  and  vein. 
dd1 ' .  Artery  and  vein  of  the  conjunctiva.  eef.  Central  artery  and  vein  of  retina. 
f.  Blood-vessels  of  the  inner,  and,  g,  of  the  outer  optic  sheath,  h.  Vorticose  vein. 
i.  Posterior  short  ciliary  vein  confined  to  the  sclerotic,  k.  Branch  of  the  posterior  short 
ciliary  artery  to  the  optic  nerve.  /.  Anastomosis  of  the  choroidal  vessels  with  those  of 
the  optic  nerve,  m.  Chorio-capillaris.  n.  Episcleral  branches,  o.  Recurrent  choroidal 
artery.  /.  Great  circular  artery  of  iris  (transverse  section),  q.  Blood-vessels  of  the 
iris.  r.  Ciliary  process.  .?.  Branch  of  a  vorticose  vein  from  the  ciliary  muscle,  u.  Cir- 
cular vein.  v.  Marginal  loops  of  vessels  on  the  cornea,  -cu.  Anterior  artery  and  vein  of 
the  conjunctiva. 


24  A    MANUAL   OF    CLINICAL   OPHTHALMOLOGY. 

lid,  and  conjunctiva;  the  supraorbital,\\\z  superior  rectus 
and  levator  palpebne  muscles,  inner  canthus,  skin  and  mus- 
cles of  the  forehead  ;  the  two  palpebral,  the  lids ;  the  nasal, 
a  branch  to  the  lacrymal  sac ;  the  short  ciliary,  pierce  the 
sclera  around  the  optic  nerve  and  are  the  main  supply  to 
the  choroid  ;  the  long  ciliary,  supply  the  ciliary  body  and  iris  ; 
the  anterior  ciliary,  given  off  from  the  muscular,  perforate 
the  sclera  near  the  limbus,  and  supply  the  ciliary  body  and 
iris;  the  hvo  muscular,  supply  the  external  ocular  muscles. 


LYMPH  SYSTEM. 

Lymph  vessels,  with  their  own  walls,  are  found  in  the 
lids  and  conjunctiva,  and  empty  into  the  parotid  and  sub- 
maxillary  glands,  accompanying  the  venae  facialis  and  tem- 
poralis.  In  the  conjunctiva  is  a  superficial  and  deep  net- 
work of  canals  communicating  freely  with  one  another,  and 
in  close  connection  with  the  lymph  systems  of  the  cornea 
and  sclera.  The  spaces  in  the  cornea  communicate  prob- 
ably with  the  great  lymph  space  of  the  anterior  chamber 
by  means  of  Schlemm's  canal  and  the  spaces  of  Fontana. 
On  the  sclera  lies  another  lymph  space,  Tenon  s  capsule, 
composed  of  two  layers  of  delicate  connective  tissue,  an 
inner,  episcleral,  and  an  outer,  muscular  layer.  The  inner 
lies  immediately  on  the  sclera  as  far  forward  as  the  insertion 
of  the  tendons,  where  it  is  reflected  into  the  outer.  Between 
the  tendons  it  is  carried  forward  nearer  the  cornea,  and  is 
there  reflected.  Both  layers  are  lined  with  epithelium  and 
extend  backward  to  the  foramen  sclera,  communicating 
with  the  intervaginal  lymph  space.  Between  the  sclera  and 
choroid  is  a  third  space,  the  pcricJioroidca,  communicating 
with  Tenon's  capsule  by  fine  canals  through  the  sclera.  The 
vitreous  body  and  lens  are  nourished  by  the  surrounding 


MUSCLES.  25 

blood-vessels  of  the  uveal  tract,  and  do  not  certainly  possess 
lymph  vessels  proper,  as  does  the  cornea.  In  the  foetus,  the 
lens  is  nourished  by  the  hyaloid  artery,  which  is  given  off 
from  one  of  the  branches  of  the  arteria  centralis  retinae, 
and  pursues  a  straight  course  through  the  vitreous,  termi- 
nating in  fine  branches  on  its  posterior  lenticular  surface. 

It  is  said  that  from  the  ciliary  body  a  stream  of  lymph 
flows  downward  and  backward  through  the  vitreous,  then 
forward  and  through  the  canal  of  Petit  to  the  posterior 
chamber ;  downward  and  forward  through  the  pupil  into 
the  anterior  chamber,  and  outward  to  the  angle,  whence  it 
escapes  through  the  membrane  of  Descemet  and  ligamentum 
pectinatum  to  the  canal  of  Schlemm.  Tributary  streams  of 
lymph  flow  into  the  posterior  chamber  from  the  posterior 
surface  of  the  iris  and  from  the  ciliary  body,  and  into  the 
anterior  chamber  from  the  anterior  surface  of  the  iris  and 
meshes  of  Fontana's  space.  The  corneal,  scleral,  con- 
junctival,  perichoroidal,  and  Tenon's  lymph  spaces  also 
communicate  with  the  anterior  chamber.  The  lymph 
canals  of  the  retina  accompany  the  retinal  vessels  and 
discharge  through  the  poms  opticus. 


MUSCLES. 

The  position  of  the  eyeba.ll  in  the  orbit  is  maintained 
and  its  movements  governed  by  the  action  of  six  muscles, 
namely,  four  straight  and  two  oblique.  The  recti,  superior, 
inferior,  external,  and  internal,  and  the  superior  oblique  have  a 
nearly  common  origin  from  the  margin  of  the  optic  foramen 
in  the  lesser  wing  of  the  sphenoid  bone.  The  recti,  diverg- 
ing in  the  directions  indicated  by  their  names,  run  forward 
parallel  to  the  orbital  wall,  perforate  the  capsule  of  Tenon, 
and  are  inserted  into  the  sclera  at  distances  varying  from  six 
3 


26 


A    MANUAL   OF   CLINICAL   OPHTHALMOLOGY. 


to  eight  mm.  from  the  cornea.  The  superior  oblique  passes 
forward  and  upward  to  the  upper  and  inner  angle  of  the 
orbit,  thence  through  a  bony  and  cartilaginous  pulley  out- 
ward and  backward  under  the  superior  rectus,  to  be  inserted 
into  the  sclera  on  its  posterior  and  superior  surface.  The 
inferior  oblique  arises  from  a  depression  in  the  superior 


FIG.  ii. 


LATERAL  VIEW  OF  THE  MUSCLES  OF  THE  EYEUAI.I.. 

5.  Trochlea  or  pulley  of  the  superior  oblique  muscle.     /,  z,  6.  Optic  nerve.     8.  Superior, 
9,  inferior,  and  12,  external  rectus.    13.  Inferior  oblique. 


maxillary  bone  at  the  inferior  and  anterior  angle  of  the 
median  wall  of  the  orbit,  passes  outward  and  backward 
under  the  globe,  and  is  attached  to  the  sclera  on  its  external 
and  posterior  surface. 

The  Uvator palpebra  arises  from  the  upper  portion  of  the 
bony  wall  of  the  optic  foramen,  passes  forward  and  upward 


THE   APPENDAGES    OF   THE    EYE.  2/ 

to  be  inserted  into  the  cartilage  of  the  upper  lid.  Its  func- 
tion is  to  elevate  the  lid. 

The  orbicularis  palpebrarum  is  a  broad,  circular  muscle, 
arising  from  the  inner  canthus  and  from  the  soft  tissues  im- 
mediately adjacent  to  the  nose,  passes  under  the  skin  of  the 
lids  and  between  them  and  the  orbital  ridges,  and  is  inserted 
close  to  its  origin.  By  its  contraction  the  lids  are  closed. 

The  optic  axis  is  a  line  drawn  from  the  centre  of  the 
cornea  to  the  centre  of  the  retina.  The  ends  are  called 
respectively  anterior  and  posterior  poles. 

The  visual  axis  is  a  line  drawn  from  the  fovea  centralis  to 
the  object  in  view. 

The  angle  a  is  formed  at  the  intersection  of  the  visual 
with  the  optic  axis.  In  H.*  it  is  usually  larger  and  may 
cause  an  apparent  divergence.  In  M.  it  is  small,  or  may  be 
absent  (negative),  i.  e.,  the  optic  and  visual  axes  coincide. 
This  may  give  rise  to  the  appearance  of  convergence.  The 
angle  Y  is  at  the  centre  of  rotation  of  the  ball,  and  is  the 
angle  formed  at  the  junction  of  a  line  drawn  from  the  cen- 
tre of  rotation  to  the  object  in  view  with  the  optic  axis. 

THE    APPENDAGES    OF    THE    EYE. 

The  lids  (Fig.  12)  are  composed  of  skin,  muscle,  dense, 
fibrous  tissue  or  cartilage,  the  tarsus,  and  mucous  mem- 
brane. The  cutaneous  layer  of  the  upper  lid,  containing 
partly-developed  papillae  and  numerous  fine  hairs  and  some 
sweat  glands,  is  loose  and  distensible  ;  at  the  margin  it 
becomes  modified,  and  is  continued  on  the  under  sur- 
face, where  it  becomes  mucous  membrane.  Connective 
tissue  in  wide  meshes,  highly  vascular,  separates  the  in- 

*  Abbreviations :  E.  Emmetropia.  II.  Hypermetropia.  M.  Myopia.  As. 
Astigmatism. 


28  A   MANUAL   OF   CLINICAL  OPHTHALMOI .<  ><  .V. 

FIG.  12. 


to- 


YIKIICAL  SKCTION  THROUGH  THK  UITER  KYKI.II>. 

.1.  ('mis;  i.  Epidermis;  2.  Corium  ;  t>.  and  3.  Subcutaneous  connective-tissue;  C.  and  7. 
Orbicularis  muscle  ;  D.  Loose  submuscular  connective  tissue;  E.  Insertion  of  H.  Miil- 
ler's  muscle;  F.  Tarsus;  G.  Conjunctiva;/.  Inner,  A".  Outer  edge  of  the  lid  ;  4.  Pig- 
ment cells  ;  5.  Sweat-gland  ;  6.  Hair  follicles  ;  8  and  23,  Sections  of  nerves  ;  9.  Arter- 
ies ;  10.  Veins;  n.  Cilia;  12.  Modified  sweat-glands :  13.  Circular  muscle  of  Riolan  ; 
14.  Meibomian  gland;  15.  Section  of  an  acinus  of  the  same;  16.  Posterior  tarsal 
glands,  submuscular  connective  tissue  ;  ai  and  22.  Conjunctiva,  with  its  epithelium  ; 
24.  Fat;  25.  Loosely-woven  posterior  end  of  the  tarsus;  26.  Section  of  a  palpebral 
artery. 


THE   CONJUNCTIVA.  29 

tegument  from  the  second  or  muscular  layer,  the  lid  por- 
tion of  the  orbicularis  palpebrarum.  The  tarsus  of  the 
upper  lid  consists  of  dense,  closely-interwoven  fibrous 
tissue,  connected  rather  loosely  with  the  muscle  above  and 
closely  with  the  mucous  membrane  below.  It  is  9  mm.  in 
height,  20  mm.  in  length,  and  .8  mm.  in  thickness.  Into  its 
upper  margin  is  inserted  the  tendon  of  the  levator  palpebrae. 
The  lower  border  is  free  and  in  its  substance  are  found 
tarsal  or  meibomian  glands  and  hair  follicles,  the  ciliae. 

In  the  lower  lid  the  cartilage  is  almost  undeveloped,  and 
the  glands  are  fewer  and  relatively  insignificant. 


CONJUNCTIVA. 

The  conjunctiva,  continuous  with  the  Schneiderian  mu- 
cous membrane  of  the  nose  and  the  integument  of  the 
lids  at  their  free  margins,  is  a  mucous  membrane  com- 
posed of  columnar  epithelium  with  its  basement  mem- 
brane, and  is  richly  supplied  with  vessels  and  nerves.  It 
is  divided  into  palpebral,  the  portion  lying  in  juxtaposi- 
tion to  the  lid ;  fornix,  the  upper  and  lower  cul-de-sac, 
where  the  conjunctiva  leaves  the  lid  and  is  reflected  over 
into  the  sclera,  and  ocular,  the  portion  lying  on  the  ball. 
The  epithelium  is  continued  over  the  cornea,  forming  its 
first  layer,  while  the  loose,  connective  tissue  ends  at  the 
corneo-scleral  margin.  The  palpebral  portion  is  thick, 
contains  numerous  papillae  and  glands,  and  is  highly  vas- 
cular. The  ocular  conjunctiva  is  less  dense,  loosely  con- 
nected with  adjacent  parts,  and  transparent.  The  conjunc- 
tiva forms  a  small  fold  at  the  inner  angle,  \\\&  plica  scniilnnaris, 
adjoining  which  on  the  nasal  side  is  a  small  conical  body, 
caruncula  laaymalis,  composed  of  muscular  fibre,  fat,  and 
mucous  membrane,  and  supporting  a  few  fine  hairs. 


A    MANUAL   OF    CLINICAL   OPHTHALMOLOGY. 


LACRYMAL  APPARATUS. 

The  lacrymal  gland,  which  secretes  the  tears,  is  held  by  a 
few  fibrous  bands  in  a  depression  in  the  frontal  bone  at  the 
upper  and  outer  angle  of  the  orbit.  Its  under  surface  rests 
upon  the  ball  and  adjacent  portions  of  the  superior  and  ex- 
ternal recti  muscles.  It  is  about  the  size  and  shape  of  an 
almond,  and  opens  into  the  outer  and  upper  fornix  by  a 


FIG.  13. 


LACRYMAL  APPARATUS. 

i.  Upper  lid.  2.  Lower  lid.  3.  Canaliculi. 
4.  Lacrymal  sac.  5.  Puncta.  6.  Plica 
semilunaris.  7.  Caruncula.  8.  Nasal 
duct.  9.  Lacrymal  gland.  10.  Tubules. 


number  of  tubules,  through  which  the  tears  are  conveyed 
into  the  conjunctival  sac.  From  this  point,  tears  flow  over 
the  conjunctiva  and  cornea,  cleansing  and  lubricating  these 
parts,  and  are  forced  by  winking  into  the  f>nncta  lacryinalia, 
two  small  openings  opposite  one  another  near  the  nasal 
extremity  of  the  ciliary  borders  of  upper  and  lower  lids; 
thence  into  the  caiialiculi,  two  small  canals  1 2  mm.  long,  by 


ACCOMMODATION.  3! 

which  they  are  conveyed  into  the  lacrymal  sac,  the  expanded 
upper  extremity  of  the  nasal  duct.  The  sac  is  lodged  in  a 
depression  formed  by  the  lacrymal  and  nasal  process  of  the 
superior  maxillary  bone,  and  is  covered  and  compressed  by 
the  tendo-tarsi  muscle  and  by  the  fibrous  expansion  of  the 
tendo-oculi.  From  the  sac  the  tears  pass  into  the  nasal  duct, 
a  membranous  and  bony  canal,  20  mm.  long,  emptying 
into  the  inferior  meatus  of  the  nose. 


ACCOMMODATION. 

By  accommodation  is  meant  the  power  that  resides  in 
the  ciliary  muscle  of  so  altering  the  length  of  the  antero- 
posterior  diameter  of  the  lens,  that  the  eye  becomes  adapted 
in  its  focal  length  to  any  distance  within  infinity.  By 
contraction  of  the  radiating  fibres  of  the  ciliary  muscle 
toward  their  fixed  points  in  the  choroid,  the  angle  of  the 
anterior  chamber  is  drawn  inward  and  backward,  while  the 
diameters  of  the  lens  are  simultaneously  shortened  by  the 
contraction  of  the  circular  fibres  of  the  same  muscle.  The 
effect  of  this  double  contraction  is  to  relax  the  suspensory 
ligament  of  the  lens.  Thus  in  the  act  of  accommodating 
the  lens  is  increased  in  convexity,  the  iris  is  contracted, 
and  the  anterior  chamber  becomes  shallower.  (Fig.  14.) 

Accommodation  is  said  to  be  positive  or  negative.  It  is 
positive  when  the  ciliary  muscle  contracts  in  the  manner 
just  described,  and  negative  when  the  refracting  power  of 
the  lens  is  difriinished  instead  of  increased,  and  this  is 
accomplished,  theoretically,  by  supposing  the  angle  of  the 
anterior  chamber  to  be  the  fixed  and  the  choroid  the  mov- 
able points,  inducing  a  flattening  of  the  lens  or  a  positive 
diminution  in  the  antero-posterior  diameter  of  the  vitreous 
by  a  dragging  forward  of  the  choroid  and  retina. 


32  A    MANUAL   OF   CLINICAL   OPHTHALMOLOGY. 

The  range  of  accommodation  is  the  distance  from  the  far 
point,  r,  to  the  near  point,  p.  The  amplitude  of  accom- 
modation is  the  accommodative  effort  of  which  an  eye 
is  capable,  and  is  equal  to  the  difference  between  the  refrac- 
tion when  the  eye  is  at  rest,  or  adapted  for  its  far  point  (/•), 
and  when  the  accommodation  is  exercised  to  its  fullest 
extent  (/>).  Hence  a  —  p  —  r.  Example  :  in  emmetropia, 


FIG.  14. 


SCHEME  OF  ACCOMMODATION  FOR  NEAR  AND  DISTANT  ' 

The  right  side  of  the  figure  represents  the  condition  of  the  lens  during  accommodation  for 
a  near  object,  and  the  left  side  when  the  eye  is  at  rest.  The  letters  indicate  the  S.IIM-- 
parts  on  both  sides  ;  those  on  the  right  side  are  marked  with  a  dash.  A.  Left,  /»'  right 
half  of  the  lens;  C.  Cornea;  S.  Sclerotic;  CS.  Canal  of  Schlemm  ;  /"A".  Anterior 
chamber  ;  J.  Iris;  P.  Margin  of  the  pupil ;  V,  Anterior  surface  ;  //.  Posterior  surface 
of  the  lens;  R.  Margin  of  the  lens  ;  /•'.  Margin  of  the  ciliary  processes  ;  a  and  b.  Space 
between  the  two  former;  the  line  ZX  indicates  the  thickness  of  the  lens  during  accom- 
modation for  a  near  object  ;  /.Y.  The  thickness  of  the  lens  when  the  eye  is  p.. 


p  =  6  cm.,  r  =  oo  (infinity) ;  a  =  6  cm.  —  oo  ;  a  =  6  cm., 
or  its  range  extends  from  infinity  to  a  point  6  cm.  from  the 
eye.  Its  amplitude  or  power  expressed  in  diopters  is 
obtained  thus:  6  cm.  divided  into  100  =  16.6  diopters. 
In  other  words,  a  convex  glass,  16.6"  placed  before  the  eye 
makes  parallel  the  rays  which  diverge  from  the  near  point 
and  substitutes  the  greatest  contraction  of  the  ciliary  muscle. 


ACCOMMODATION.  33 

RELATIVE  ACCOMMODATION. 

Accommodation  and  convergence  bear  a  constant  relation 
to  one  another,  within  the  limits  of  the  amplitude  of  ac- 
commodation on  the  one  hand  and  the  amplitude  of  con- 
vergence on  the  other.  Thus  with  the  visual  lines  parallel, 
accommodation  may  be  determined  by  placing  before  the 
eyes  minus  glasses  of  constantly  increasing  strength.  The 
highest  number  that  can  be  overcome,  vision  always  f ,  is 
the  measure  of  the  accommodation  exercised  independently 
of  convergence.  Convergence,  when  accommodation  re- 
mains unchanged,  may  be  estimated  by  prisms.  The 
strongest  prism,  angle  in,  through  which  binocular  vision 
is  maintained  at  6  m.,  is  the  measure  of  the  limit  of  the 
converging  power,  independent  of  accommodation.  The 
strongest  prism,  angle  out,  through  which  single  vision  is 
maintained  under  the  same  conditions,  is  the  measure  of  the 
limit  of  minus  convergence. 

Tlie  Metre  Angle. — For  every  distance  nearer  than  6  m., 
convergence  bears  a  fixed  relation  to  accommodation. 
Thus,  by  the  exercise  of  I  D.  of  accommodation  in  emme- 
tropia,  the  internal  recti  so  direct  the  visual  axes  that  they 
cross  at  I  m.  from  the  basal  line  uniting  the  two  eyes,  and 
form  with  the  perpendicular  to  that  line  at  its  centre,  an 
angle,  called  the  metre  angle.  By  the  exercise  of  2  D.  of 
accommodation,  the  convergence  will  equal  two  metre 
angles,  with  3  D.  of  accommodation  it  will  equal  three 
metre  angles,  and  so  on.  Again,  if  the  object  is  situated 
at  i  m.,  convergence  will  equal  one  metre  angle,  if  at  50 
cm.,  it  will  equal  two  metre  angles,  etc. 
4 


34  A    MANUAL   OF    CLINICAL   OPHTHALMOLOGY. 

TEST   CARDS,  TEST  LENSES,  ETC. 

The  test  letters  commonly  in  use  are  so  constructed  that 
their  vertical  diameter  shall  be  the  sine  of  the  angle  of  5'. 
Suppose  two  lines  are  drawn,  one  from  the  top  and  the  other 
from  the  bottom  of  such  a  letter,  so  that  they  meet  in  the 
lens  of  an  eye.  They  are  not  mathematically  parallel,  but 
they  are  so  nearly  parallel  that  the  angle  of  5'  which  they 
form  with  each  other,  at  their  crossing  point  in  the  posterior 
part  of  the  lens,  is  disregarded,  and  they  are  considered 
parallel.  This  angle  is  chosen,  because  it  is  the  smallest 
which  includes  recognizable  objects.  But  mathemati- 
cally parallel  rays  can  come  only  from  an  object  at  an 
infinite  distance.  Hence  we  say  that  all  objects  included 
in  the  lines  forming  this  angle  are  at  an  infinite  distance. 
The  farther  removed  from  the  eye  the  greater  the  size 
of  such  objects  must  be,  although  their  images  on  the 
retina  are  of  the  same  size.  Thus,  the  card — 


50  BN 

=  A 

40  ER 

=  1 

30   N  C  D 

=  £ 

20    P  R  F  H 

i 

15    LCBDT 

& 

10    EPGBU 

a 

5      TCNDEOF      —      1 

The  extremities  of  the  vertical  lines  of  B  N  measure  the 
sine  of  the  angle  of  5'  at  50  m.  The  normal  eye  sees  B  N 
at  50  m.,  but  at  no  greater  distance ;  E  R  at  40  m.,  but  at 
no  greater  distance ;  TCNDEOF  at  5  m.,  but  at  no 
greater  distance.  The  acuity  of  vision  is  expressed  by  a 
fraction,  the  numerator  of  which  is  the  distance  of  the 


TEST    CARDS,    TEST    LENSES,    ETC. 


35 


patient  from  the  test-card,  and  the  denominator  the  line  he 
reads  at  that  distance.  Hence,  normal  acuity  equals  f,  f , 
or  i.  A  diminished  acuity  would  be,  for  example,  ^5-,  -/$. 
If  the  acuity  should  be  so  low  that  B  N  cannot  be  seen  at 
5  m.,  we  must  bring  the  card  closer  to  the  patient  or  use 
larger  letters. 

FIG.  15. 


TEST  CASE. 


The  metric  system  of  numbering  lenses  according  to 
their  refracting  power  and  not  according  to  their  focal 
length,  as  in  the  obsolete  inch  system,  is  now  universally 
employed  by  properly  equipped  ophthalmic  surgeons  and 
opticians.  A  lens  which  will  bend  parallel  rays  of  light  to 
a  focus  at  the  distance  of  I  m.  is  called  "  I  Diopter," 


36  A    MANUAL   OF    CLINICAL   OPHTHALMOLOGY. 

expressed  I  D.  The  word  diopter,  literally  signifying  the 
refractive  media  of  the  eye,  is  transferred  to  the  glass. 
One-half  diopter  (.50  D.)  will  focus  parallel  rays  at  the  dis- 
tance of  2  m.,  2  D.  at  y2  m.,  3  D.  at  %  m.,  4  D.  at  ^  m.,  etc. 
The  weakest  lens  ordinarily  used  is  .25  D.,  4  m.  in  focal 
length,  and  the  strongest  20  D.,  5  cm.  in  focal  length. 

The  refracting  power  of  a  minus  lens,  negative  focal 
length,  is  the  same  as  that  of  a  plus  lens  of  the  same 
number. 

The  cylinders  are  plus  and  minus,  and  are  marked  like 
sphericals,  in  strengths  from  .25  D.  to  6  D.  Higher 
strengths,  which  are  seldom  required,  may  be  obtained  by 
superimposed  cylinders,  whose  sum  is  the  refracting  power 
desired. 

The  frame  for  holding  lenses  before  the  patient's  eyes, 
consists  essentially  of  two  circular  lens-holders,  marked  in 
degrees  from  o  to  180,  held  together  by  a  nose-piece  and 
a  horizontal  bar,  along  which  they  can  be  moved. 


FIELD   OF  VISION. 

When  refraction  and  accommodation  are  normal  and  the 
media  clear,  subnormal  vision  is  attributable  to  some  lesion 
of  the  retina,  choroid,  optic  nerve  or  cerebro-spinal  system, 
and  when  this  is  the  case,  it  becomes  necessary  to  accurately 
measure  the  field  of  vision,  the  area  over  which  objects  can 
be  seen  while  the  eye  remains  fixed  on  a  given  point.  The 
objects  thus  bounded  by  the  ultimate  range  of  peripheric 
vision  without  changing  the  direction  of  the  visual  line,  mark 
the  limits  of  the  visual  field,  which  may  be  contracted  in 
various  ways  under  pathological  influences.  The  field  may 
be  concentrically  smaller,  it  may  be  diminished  or  altogether 
lost  on  the  nasal  or  temporal  side — horizontal  hemianopsia  ; 


FIELD    OF   VISION.  37 

the  superior  or  inferior  fields  may  be  similarly  affected, 
vertical  hemianopsia,  or  irregularly  shaped  defects  may  be 
found  in  its  centre  or  elsewhere,  scotomata. 

The  sensibility  of  the  retina  rapidly  diminishes  from  the 
fovea  to  the  periphery,  and  it  should  be  remembered  that 
the  bridge  of  the  nose  considerably  limits  the  visual  field 
in  its  inner  half,  and  that  the  optic  disc  projects  a  blind 
spot  of  proportionate  size  to  the  temporal  side  of  the  fixa- 
tion point,  but  when  the  normal  field  is  diminished  in 
any  particular  section,  there  is  lessened  sensibility  of  the 
retina. 

The  visual  field  may  be  approximately  measured  by  direct- 
ing the  patient  to  sit  facing  and  about  twelve  inches  away 
from  a  blackboard  in  the  centre  of  which  a  small  white 
cross  is  marked  with  a  piece  of  chalk,  and  to  look  steadily 
at  this  cross  with  the  eye  under  examination,  the  other  eye 
being  closed,  while  the  examiner  with  a  piece  of  chalk 
attached  to  a  dark  handle  marks  on  the  blackboard  the 
points,  in  all  meridians,  at  which  it  fades  from  peripheric 
vision.  The  point  at  which  the  patient  first  sees  the  chalk 
as  it  is  moved  toward  the  centre,  or  at  which  it  disappears 
from  view  when  moved  from  the  centre,  is  marked  on  the 
blackboard,  and  is  a  measure  of  the  visual  field.  The 
quantitative  field  of  vision  thus  determined  is  not  to  be 
confounded  with  the  central  smaller  area,  or  qualita- 
tive field,  in  which  small  objects,  such  as  letters,  are  dis- 
cernible. 

The  perimeter,  a  simple  and  comparatively  inexpensive 
instrument,  exactly  defines  the  field  of  vision,  and  its 
employment  has  very  generally  superseded  measurements 
by  the  earlier  and  clumsier  methods.  It  consists  essentially 
of  an  arc  comprising  a  quadrant,  or  semicircle,  marked  in 
degrees,  and  adjustable  at  any  angle,  and  an  upright  bar  to 


3»  A   MANUAL   OF   CLINICAL  OPHTHALMOLOGY. 

which  is  attached  a  movable  chin  rest.  On  the  arc,  in  the  axis 
of  the  instrument,  is  a  white  mark  or  cross,  thirty  cm.  from 
patient's  eye,  and  a  sliding  clip  containing  white  or  colored 
test.  The  white  test  should  be  eleven  mm.,  and  the  blue, 
red  and  green  five  mm.  in  diameter.  The  patient's  ga/c  is 
directed  toward  the  cross  while  the  clip  is  moved  from 


MCHARDY'S  PERIMETER. 

the  centre  toward  the  periphery.  The  point  at  which 
it  disappears  from  the  patient's  vision  is  the  limit  of 
the  perception  of  the  retina  in  that  direction.  A  chart 
is  thus  made  and  the  visual  field  for  white  and  colors 
measured  in  degrees.  The  limit  of  the  normal  field, 
subject  to  variations  according  to  the  conformation  of  the 


COLORS.  39 

face,  for  white,  blue,  red  and  green,  is  illustrated  in  the 
following  table : — 

White.  Blue.        Red.  Green. 

Externally, 7o°-9o°        65°         60°        40° 

Internally, 5O°-6o°         60°         50°        40° 

Upwards', 45°-55°         45°         4O°         3o°-35° 

Downwards,      65°-7o°         60°         50°         35° 

(Landois  and  Stirling.) 


COLORS. 

Solar  light,  which  is  uniform  and  colorless,  is  transmitted 
through  what  we  vaguely  term  the  luminiferous  ether  in 
transverse  waves  of  varying  length,  which,  separated,  give 
rise  to  certain  visual  impressions  that  are  the  source  of  all 
color  sensations.  The  dispersion  of  a  beam  of  light  into 
its  separate  wave-lengths  is  effected  by  means  of  a  prism, 
which  disposes  them,  refracting  each  ray  in  proportion  to 
the  shortness  of  its  wave,  in  a  colored  spectrum,  or  band, 
from  which  they  can  by  reversion  through  a  similar  prism 
be  reformed  into  a  beam  of  colorless  light.  Without  going 
into  a  discussion  of  the  Young-Helmholtz,  or  Hering  the- 
ories of  color  vision,  which  are  elaborated  in  the  larger 
text-books  on  Physiology,  it  may  be  stated  that  the  so- 
called  spectrum  colors  so  shade  off,  one  into  the  other,  that 
their  division  by  name  is  largely  a  matter  of  arbitrary  ar- 
rangement. Red,  blue,  and  yellow  are  regarded  as  primary 
colors,  and  form,  by  combination,  secondary  colors,  that  is  to 
say,  combinations  of  blue  and  red  will  give  purple  and 
violet ;  yellow  and  red  combined  give  orange;  and  blue  and 
red  combined  make  green.  Our  color  sensations  admit  of 
certain  other  relations  and  combinations  of  colors,  giving 
by  association  in  one  case,  and  disassociation  in  the  other, 
respectively  complementary,  and  contrast  or  confusion  colors. 

COLOR  SENSE  is  quickly  and  most  accurately  determined 


4O  A    MANUAL   OF   CLINICAL  OPHTHALMOLOGY. 

by  the  distinction  and  separation  of  various  colors  without 
designating  them  by  name.  For  this  purpose  it  is  usual  to 
employ  Holmgren's  worsteds,  a  set  of  skeins  of  wool  made 
up  of  the  primary,  secondary,  and  confusion  or  mixed 
colors.  Among  them  are  three  large  skeins,  a  light  green, 
a  light  purple,  and  a  scarlet  red.  The  patient  is  first  asked 
to  match  the  green,  which  the  examiner  does  not  desig- 
nate by  name.  If  blind  for  green,  he  will  confuse  with  it 
grays,  browns,  yellows  and  drabs.  Or  if  blind  for  red, 
he  will  choose  purple,  blue  and  light  shades  of  violet, 

FIG.  17. 


SPECTRUM  OBTAINED  BY  MEANS  OF  A  PRISM. 


red,  gray  and  green.  If  the  patient's  color  sense  is  nor- 
mal, there  will  be  no  confusion  of  the  colors  in  separating 
the  skeins. 

COLOR-BLINDNESS. — The  question  of  congenital  achro- 
matopsia, or  color-blindness,  has  acquired  considerable  im- 
portance of  late  years,  or  since  the  discovery  of  the  fact  that 
about  i  in  25  of  the  entire  male  population  is  partially 
affected  by  it.  The  proportion  of  color-blind  is  signifi- 
cantly small  in  women,  being  about  I  in  400.  The  defect 
usually  is  not  suspected  until  its  presence  is  revealed  by 


COLORS.  41 

examination.  Railway  men,  sailors  and  soldiers  are  almost 
universally  compelled  to  undergo  an  examination  for  color- 
blindness previous  to  employment 

Acquired  achromatopsia  is  an  occasional  symptom  of 
disease  of  the  optic  nerve,  or  of  hysterical  amblyopia,  and 
is  treated  under  these  heads. 


PART  II. 
PHYSIOLOGICAL  OPTICS. 

Light  proceeds  from  all  luminous  bodies  through  "the 
ether,"  a  medium  independent  of  the  atmosphere,  by  un- 
dulations of  inappreciable  height.  The  principal  source  of 
light  is  the  sun.  We  conceive  that  all  visible  objects  con- 
sist on  their  surface  of  innumerable  luminous  points  from 
which  rays  of  light  travel  in  all  directions.  It  follows  that 
some  of  the  diverging  rays  from  each  luminous  point  must 
enter  the  pupil  of  the  eye  in  straight  parallel  lines.  Rays 
are  assumed  to  be  parallel,  in  physiological  optics,  that 
proceed  from  a  small  object  removed  6  m.  or  more  from  the 
eye,  and  an  object  thus  far  removed,  is  said  to  be  at  an  in- 
finite distance. 

Refection  is  the  bending  or  turning  back  of  a  ray  of  light 
from  a  surface  that  neither  absorbs,  transmits,  nor  scatters  it. 

Refraction  is  the  deviation  of  light  from  a  straight  line 
in  passing  obliquely  through  transparent  media  of  different 
densities. 

The  index  of  refraction  of  a  substance  expresses  in  num- 
bers the  relative  power  that  medium  possesses  of  bending 
oblique  rays  of  light  which  pass  through  it,  away  from  the 
direction  pursued  by  them  before  entering  it,  or  the  ratio 
of  the  sine  of  the  angle  of  incidence  to  the  sine  of  the 
angle  of  refraction.  The  index  of  refraction  of  air  is  taken 
as  I,  that  of  water,  as  1.336  (sin.  :  i.  :  sin.  :  r.  :  :  4  :  3);  that 
of  glass,  as  1.535  (sin. :  i.  :  sin.  :  r.  :  :  3:2). 

42 


PHYSIOLOGICAL   OPTICS.  43 

In  passing  from  one  medium  to  another  of  different 
density — air  to  glass — a  ray  of  light,  a  a,  entering  the  second 
medium  perpendicular  to  its  surface  continues  its  course 
unchanged.  (Fig.  18.)  On  the  other  hand,  an  oblique  ray, 
b,  passing  from  a  lighter  to  a  denser  medium,  ;//,  is  bent 
toward  the  perpendicular,  and  from  a  denser  to  a  lighter 
medium  away  from  the  perpendicular,  and  if  the  two  sides 
of  the  refracting  medium  are  parallel,  the  emerging  ray,  b, 
pursues  its  course  parallel  to  the  incident  ray,  simply  under- 
going parallel  displacement. 

FIG.  1 8. 


REFRACTION  BY  MEDIUM  WITH  PARALLEL  SIDES. 

The  angle  of  incidence,  x,  equals  the  angle  of  emer- 
gence, y. 

The  incident  and  emergent  rays  are  not  parallel,  how- 
ever, when  a  ray  of  light  traverses  a  medium  with  non- 
parallel  surfaces,  but  are  angularly  displaced.  In  physio- 
logical optics  we  simply  apply  the  law  of  angular  deviation 
experienced  by  a  ray  of  light  in  its  course  through  a 
medium  of  non-parallel  surfaces.  This  law  is  best  studied 
in  the  action  of  a  prism  upon  rays  of  light. 

Thus  (Fig.  19),  in  the  prism  ;//,  b  is  the  incident,  and  b' 


44  A    MANUAL   OF   CLINICAL   OPHTHALMOLOGY. 

the  emergent,  ray.  It  is  thus  shown  that  the  rays  of  light 
are  always  bent  toward  the  base  of  the  prism,  while  the 
source  of  the  rays  is  apparently  displaced  toward  the  apex,  a. 
The  angle  formed  by  the  meeting  of  the  prolongation  of 
the  incident  and  emergent  ray  is  the  angle  of  deviation, 
and  is  about  one-half  the  size  of  the  apex  angle. 

Prisms  are  numbered  according  to  the  number  of  degrees 
included  in  the  apex.  A  new  nomenclature  by  which  they 
shall  be  numbered  according  to  their  refractive  power,  or 
size  of  angle  of  refraction,  is  under  discussion. 

FIG.  19. 


REFRACTION  BY  A  PRISM. 

The  lenses  used  for  the  correction  of  spherical  errors  of 
refraction  are  of  two  kinds  (Fig.  20),  and  may  be  practically 
considered  as  formed  by  two  juxtaposed  prisms  which, 
joined  by  their  bases,  form  convex,  and,  by  their  apices, 
concave  lenses.  Bearing  in  mind  that  in  the  case  of  a  lens, 
as  in  a  prism,  the  rays  are  always  refracted  toward  its  base 
(thickest  portion),  the  subject  is  greatly  simplified.  It  is 
obvious  that  rays  of  light  are  made  to  converge  by  the 
action  of  a  convex,  and  to  diverge  by  the  action  of  a 
concave,  lens. 


PHYSIOLOGICAL   OPTICS. 


45 


The  lenses  commonly  used  in  ophthalmic  practice  are 
made  of  flint  glass  or  pebble  rock  crystal,  and  form  either 
the  segment  of  a  sphere,  spherical  glasses,  or  the  segment 


FIG.  20. 


of  a  cylinder,  cylindrical  glasses.  Both  influence  alike  the 
course  of  rays,  but  spherical  glasses  having  a  centre  of  cur- 
vature form  images,  while  cylindrical  glasses,  having  no 


FIG.  21. 


DIFFERENT  FORMS  OF  SPHERICAL  LENSES. 


curve  parallel  to  their  axes,  focus  all  incident  rays  into  a 
line  parallel  to  the  axis  of  the  cylinder. 

Six    modifications  of  spherical    lenses   are  employed — 
double  convex,  plano-convex,  converging  concavo-convex, 


46  A    MANUAL   OF   CLINICAL   OPHTHALMOLOGY. 

Kir.    22. 

I  I 


REFRACTION  OF  PARALLEL,  DIVERGING  AND  CONVERGING  RAYS  HY 
CONVEX  LENS. 


PHYSIOLOGICAL   OPTICS.  47 

or  parabolic,  double  concave,  plano-concave,  and  diverging 
concavo-concave.  In  Fig.  21  these  lenses  are  shown  in  the 
order  named,  from  left  to  right. 

The  centre  of  the  lens  is  called  the  optical  centre,  o,  (Fig. 
22,  I).  The  principal  axis,  m  m,  is  a  line  passing  through 
the  optical  centre  perpendicular  to  the  surface,  and  is  not 
refracted.  All  other  rays  are  refracted,  but  those  passing 
through  the  optical  centre  undergo  but  slight  refraction, 
emerge  in  the  same  direction  as  they  entered,  and  are 
called  secondary  axes,  n  n. 

Rays  of  light  in  passing  through  a  convex  lens  parallel 
to  its  axis,  a,  II,  converge  to  a  point  on  its  distal  side,  the 
principal  focns,  f.  The  distance  from  the  centre  of  the 
lens  to  the  principal  focus  is  the  focal  distance  of  the  lens, 
o  f,  and  the  degree  of  bending,  or  the  refraction  of  the 
rays,  as  controlled  by  the  index  of  refraction  and  the  curve 
of  the  surfaces,  is  the  refracting  power.  Converging  incident 
rays  also  come  to  a  focus,  b,  III,  on  the  distal  side  at  a  point 
nearer  to  the  lens  than  its  principal  focus,  f,  and  diverg- 
ing incident  rays  focus  to  a  point,  1,  IV,  which  is  farther 
removed  than  the  principal  focus,  f.  It  follows  that  incident 
rays  diverging  from  the  principal  focus  emerge  in  parallel 
lines  ;  that  incident  rays  diverging  from  a  point  nearer  to  the 
lens  than  its  principal  focus,  diverge  on  emerging;  and, 
lastly,  that  incident  rays  diverging  from  a  point  farther  from 
the  lens  than  its  principal  focus,  converge  on  emerging. 

The  nearer  the  principal  focus  the  greater  the  refracting 
power  of  the  lens. 

CONCAVE  LENSES  AND  THEIR  ACTION  ON  RAYS  OF  LIGHT. — 
In  passing  through  a  concave  lens,  parallel  rays  a  b,  a'  b' 
(Fig.  23),  are  rendered  divergent,  c  d,  c'  d',  as  if  proceed- 
ing from  a  point  F  on  the  line  of  the  principal  axis  between 
and  on  the  same  side  of  the  lens  with  the  parallel  incident 


48 


A    MANUAL   OF   CLINICAL   OPHTHALMOLOGY. 


rays  (negative  form).  This  point  is  the  virtual  focus,  and  its 
distance  from  the  lens  is  the  measure  of  its  negative  foe  it  I 
length.  Rays  diverging  from  the  principal  focus  are  ren- 

FIG.  23. 


dered  still  more  divergent,  and  converging  rays  are  ren- 
dered less  converging. 

A  cylinder  (Fig.  24)   having    its  curve   in    one   direc- 

FIG.  24. 


tion  only,  must  refract  rays  of  light  in  one  direction,  namely, 
in  its  axis,  or  in  the  line  passing  through  the  summit  of  the 
curve  in  a  convex,  and  the  depth  of  the  depression  in  a  con- 


PHYSIOLOGICAL   OPTICS.  49 

cave,  cylinder,  at  right  angles  to  the  curve.  Let  us  imagine 
the  cylinder  is  composed  of  an  infinite  number  of  curved 
lines  in  juxtaposition,  each  one  being  just  wide  enough  to 
admit  of  a  single  beam  of  light.  Each  line  will  then  focus 
each  beam  to  a  point,  but  the  lines  are  in  juxtaposition, 
hence  the  points  of  focus  must  also  be  in  juxtaposition. 
Since  a  line  is  made  up  of  points,  the  focus  of  a  cylinder 
must  be  a  line.  The  refracting  power,  focal  distance,  and 
other  qualities  of  a  cylinder,  are  spoken  of  in  the  same 
meaning  as  of  a  spherical  lens,  always  bearing  in  mind  the 
fact  that  it  focuses  in  a  line  and  not  in  a  point.  The  minus 
cylinders  have  negative  qualities,  as  the  minus  sphericals. 

Around  the  lens-holders  in  the  test  frame  is  a  semicircle 
marked  in  degrees,  and  one  end  of  the  axis  of  the  cylinder 
may  be  turned  to  any  desirable  degree.  Hence  we  say, 
cyl.  ax.  90°,  or  ax.  180°,  or  ax.  zjj°,  etc.  When  adjusted  to 
the  patient's  face,  the  left  extreme  end  is  arbitrarily  chosen 
as  o°,  the  right  or  opposite  end  as  180°,  and  between  these 
extremes,  the  semicircular  bar  is  marked  at  intervals  of  5°. 

The  dioptric  system,  or  the  refracting  media  of  the  eye, 
which  influences  the  course  pursued  by  rays  of  light,  is 
composed  of  structures  which  differ  in  density  and  in  the 
curvature  of  their  surfaces,  but  it  suffices,  practically,  to 
average  the  refracting  indices  of  the  several  factors,  and  to 
consider  them  as  forming,  in  combination,  a  double  convex 
lens.  A  double  convex  lens  of  this  description  is  found 
by  intersecting  the  cornea  by  an  imaginary  line  continuous 
with  the  posterior  surface  of  the  lens.  The  focal  length 
of  the  combined  surfaces  thus  formed  is  22.23  mni-,  and 
the  media  have  a  common  index  of  refraction  of  1.33. 

Parallel  rays  impinging  upon  the  cornea  of  a  normal 
(emmetropic)  eye,  are  brought  to  a  focus  upon  the  retina 
in  the  absence  of  accommodation.  Under  the  same  condi- 


5<D  A    MANUAL  OF   CLINICAL   OPHTHALMOLOGY. 

tion  of  rest,  diverging  rays  will  come  to  a  focus,  theoreti- 
cally, at  a  point  behind  the  retina,  and  converging  rays  will 
come  to  a  focus  at  a  point  in  front  of  the  retina.  Therefore, 
in  a  normal  eye  at  rest,  rays  which  proceed  from  the  focus 
upon  the  retina  will  emerge  out  of  the  cornea  parallel,  those 
from  behind  the  retina  converging,  and  those  from  in  front 
of  it  diverging. 

In  examining  the  fundus  of  an  eye  by  the  ophthalmo- 
scope, the  foregoing  optical  principles  are  observed.  For 
instance,  if  the  observer's  eye  is  of  normal  refraction,  and 
at  rest,  not  accommodating,  the  details  of  the  fundus  of  the 
eye  under  observation  will  be  seen,  provided  the  observed 
eye  is  also  suitably  illuminated,  at  rest,  and  normal  in  its 
refraction.  Without  the  aid  of  artificial  light  the  reflection 
of  light  from  the  observed  eye,  which  is  projected  along 
the  visual  axis  of  the  two  eyes,  is  too  feeble  for  illumi- 
nation, and  the  pupil  appears  black.  The  pupil  of  observed 
eye  will  still  appear  black  when  a  light  is  interposed  in 
the  line  of  vision  between  it  and  the  observing  eye,  since 
the  two  eyes  are  adapted  to  parallel  rays  only,  and  the 
diverging  rays  from  the  interposed  light  would  illuminate 
both  eyes,  and  the  returning  rays  would  focus  at  the 
interposed  light,  as  if  proceeding  from  a  point  behind  the 
retina,  and  an  inverted  image  of  the  interposed  flame 
would  be  focused  upon  the  retinae  of  the  two  eyes.  There- 
fore, it  is  not  only  necessary,  in  order  to  see  the  fundus  of 
the  eye  under  examination,  that  the  observed  and  observ- 
ing eyes  shall  be  artificially  luminous,  but  also  that  the 
light  shall  be  placed  in  such  a  position  that  its  flame  will 
be  effective  as  a  source  of  illumination. 

This  necessary  arrangement  of  the  light  was  first  accom- 
plished by  Helmholtz,  who  constructed  an  instrument  by 
which  the  light  was  suitably  placed  behind  the  observed 


PHYSIOLOGICAL   OPTICS.  51 

eye.  The  invention  of  this  instrument,  the  ophthalmoscope, 
has  placed  ophthalmology  among  the  fixed  sciences,  and 
given  to  its  study  and  practice  an  interest  and  effectiveness 
surpassed  by  no  other  department  of  the  medical  sciences. 
Prior  to  its  discovery,  the  appearance  in  the  living  sub- 
ject of  the  intra -ocular  tissues  was  unknown.  Indeed,  our 
knowledge  of  the  subject  was  of  a  kind  with  the  belief, 
universally  held  and  taught  at  that  time,  that  there  was 
complete  absorption  of  the  light  entering  the  eye. 

FIG.  25. 


DIRECT  EXAMINATION  BY  OPHTHALMOSCOPE. 


EXAMINATION  BY  THE  OPHTHALMOSCOPE. — There  are  two 
methods  of  examining  the  eyes  by  the  ophthalmoscope, 
the  direct  and  indirect. 

By  the  former  (Fig.  25),  a  real,  erect,  and  four-fold 
magnified  image  is  seen  by  the  observer.  A  is  the  observ- 
ing, B  the  observed  eye,  55  the  plane  mirror,  and  x  the 
source  of  illumination.  The  rays  of  light  from  x  impinge 


52  A    MANUAL   OF   CLINICAL   OPHTHALMOLOGY. 

upon  the  mirror  and  are  reflected  along  the  dotted  lines 
cd  c'd'  into  B,  illuminating  the  fundus.  A,  looking 
through  opening  in  SS,  along  the  line  of  the  reflected 
rays,  sees  /?'s  retina  around  b.  The  dotted  lines  come 
to  a  focus  behind  b  at  y.  But  b  is  now  the  source  of 
illumination,  and  rays  emerging  out  of  B  pursue  a 
parallel  course  and  are  focused  by  the  dioptric  apparatus 
of  A  at  a. 

FIG.  26. 


INDIRECT  EXAMINATION  BY  OPHTHALMOSCOPE. 


By  the  indirect  method,  an  inverted  image  is  formed  in 
the  air  by  the  interposition  of  a  strong  convex  lens 
(i4D-2OD)  (Fig.  26).  M,  observer's,  K,  observed  eye ;  S,  the 
mirror.  Rays  from  the  mirror  S,  pass  through  the  lens  C 
(the  refraction  of  these  rays  is  not  shown  in  figure),  enter  K, 
and  strike  on  the  retina  at  A.  On  returning  and  being 
refracted  by  the  media  of  eye  K,  rays  enter  the  lens  C,  and 
are  focused  by  it  at  B,  forming  an  inverted  aerial  image, 
of  a  portion  of  A"s  retina. 


PART  III. 
REFRACTION. 

Normal  refraction  is  dependent  on  three  conditions: 
(i)  on  the  antero-posterior  diameter  of  the  globe,  (2)  the 
transparency  of  the  refracting  media,  and  (3)  the  curve  of 
their  surfaces.  When  an  eye  is  of  the  right  length  antero- 
posteriorly,  the  refracting  media  clear,  and  their  surfaces 
normal  in  curvature,  parallel  rays  of  light  are  brought  to  a 
focus  on  the  percipient  layers  of  the  retina,  the  rods  and 

FIG.  27. 


_£ 


CONDITION  OF  REFRACTION  IN  THE  NORMAL  PASSIVE  EYE  AND  DURING 
ACCOMMODATION. 


cones,  and  the  refraction  is  normal.  The  refraction  is  ab- 
normal when  parallel  rays  of  light  are  not  brought  to  a 
focus  on  the  retina  in  the  absence  of  accommodation. 

EMMETROPIA  is  the  term  used  to  denote  normal  refrac- 
tion. In  an  emmetropic  eye,  parallel  rays  of  light,  rr,  are 
brought  to  a  focus  (Figs.  27,  28)  on  the  retina,  rlt  without 
accommodation,  and  diverging  rays  proceeding  from  a 
point,  p,  nearer  than  infinity,  are  brought  to  a  focus  on 

53 


54  A    MANUAL   OF   CLINICAL   OPHTHALMOLOGY. 

the  retina,  /t,  by  the  exercise  of  a  normal  amount  of 
accommodation.  Such  an  eye,  to  be  exact,  will  recog- 
nize any  properly  illuminated  object  whose  height  is  equal 
to  the  sine  of  an  angle  of  5'.  An  emmetropic  eye  of  nor- 
mal acuity  of  vision  is  an  extremely  rare  condition,  about 
four  per  cent. 

A  normal  refraction  and  a  normal  eye  are  distinct  and 
separate  conditions,  and  should  not  be  confounded.  An 
eye  may  be  of  normal  refraction  and  yet  be  blind  from 
disease. 

AMETROPIA  is  a  generic  term  used  to  express  variations 

Fie.  28. 


CONDITION  OK  REFRACTION  IN  THE  NORMAL  EYE  DURING  ACCOMMODA- 

TION. 


from  the  normal  refraction,  and  has  no  reference  to  the 
kind  or  degree  of  refractive  error.  An  ametropic  eye  may 
be  hypermetropic,  myopic,  or  astigmatic. 

HYPERMETROPIA,  HYPEROPIA  (Fig.  29).  is  the  most  preva- 
lent form  of  ametropia,  and  is  that  condition  of  refraction 
in  which  parallel  rays  of  light  are  never  focused  when  the 
eye  is  at  rest,  that  is  to  say,  when  the  eye  is  not  accom- 
modating. The  curvature  of  the  cornea  and  of  the  lens, 
one  or  both,  is  so  altered  that  parallel  rays  are  intercepted 
by  the  retina  before  they  converge  to  a  focus.  In  other 
words,  the  antero-posterior  diameter  of  the  eye,  the  distance 
between  the  apex  of  the  cornea  and  the  layer  of  rods  and 


REFRACTION.  55 

cones,  is  too  short.  Such  an  eye  is  adapted  to  converging 
rays.  By  contraction  of  the  ciliary  muscle,  the  curvature 
of  the  anterior,  and  possibly  the  posterior,  surface  of  the  lens 
is  made  more  convex,  and  its  antero-posterior  diameter 
is  thus  increased.  In  emmetropia  this  contraction  of 
the  ciliary  muscle,  accommodation,  is  only  necessary  for 
the  perception  of  points  of  an  object  nearer  the  eye  than 
six  metres.  In  hypermetropia,  on  the  other  hand,  no  point 
can  be  seen  at  any  distance  without  accommodation. 
Hypermetropia  is  said  to  be  latent  when  it  is  concealed 
by  constant  contraction  of  the  ciliary  muscle ;  and  hyper- 

FIG.  29. 


HYPERMETROPIC  EYE. 

metropia  which  the  contraction  of  the  ciliary  muscle,  or 
accommodation,  cannot  overcome  is  said  to  be  manifest. 
The  sum  of  the  two,  latent  and  manifest,  constitute  the 
total  hypermetropia.  The  degrees  of  latent  and  manifest 
hypermetropia  depend  on  the  power  of  accommodation, 
the  elasticity  of  the  crystalline  lens,  and  on  the  length  of 
the  globe  antero-posteriorly.  The  total  hypermetropia 
depends  on  the  antero-posterior  diameter  of  the  eye  alone. 
The  symptoms  of  latent  hypermetropia  will  depend  on 
the  age,  sex,  occupation,  and  on  the  acquired  and  heredi- 
tary predisposition  of  the  patient.  A  well-marked  case 
will  complain  of  headache,  either  constant  or  following  near 


56  A   MANUAL  OF   CLINICAL   OPHTHALMOLOGY. 

use  of  the  eyes,  pain  in  the  eyes,  blurring  of  letters  in  reading, 
and  lacrymation.  No  complaint  will,  be  made  of  bad  visi<  >n. 
The  diagnosis  may  be  partially  made  by  the  ophthalmo- 
scope, but  it  can  only  be  completely  and  satisfactorily 
determined  by  retinoscopy,  or  by  test  lenses  after  the 
accommodation  has  been  paralyzed  by  a  mydriatic.  Let 
us  illustrate  this  by  a  case :  A  young  man,  clerk,  age 
twenty,  has  suffered  for  several  years  from  a  nearly  con- 
stant headache,  which  is  aggravated  by  his  long  hours  of 
office  work.  General  treatment  and  hygiene  have  afforded 
no  relief,  and  he  has  given  up  reading  at  night  on  account  of 
consequent  pain.  V.  =  £ ,  made  worse  by  plus,  perhaps  im- 
proved by  weak  minus  lenses.  Ophthalmoscope  shows 
normal  fundus.  Headache  relieved  in  three  quarters  of  an 
hour  after  instillation  of  Duboisine,  gr.  ij-Sj,  but  V.  de- 
clined to  -j6^.  Ophthalmoscope  gives  +  2D,  Retinoscopy 
-|-  2°,  and  -f  2D=£.  Latent  Hypermetropia  =  2D.  By 
means  of  constant  over-action  of  the  ciliary  muscle,  the 
patient  was  enabled  to  increase  the  antero-posterior  diameter 
of  the  lens  two  diopters. 

The  symptoms  of  combined  manifest  and  latent  hyper- 
metropia,  are  defective  vision,  blurring  of  letters  in  reading, 
headache,  and  pain  in  eyes,  aggravated  by  their  use  in  near 
work.  Case : — V.  fy,  -f  Is  =  $ .  During  paralysis  of  accom- 
modation, V.  =  ^,  -f  38  =  f .  Order,  -f  2.50"  for  constant 
use.  In  this  case  the  manifest  hypermetropia  equals  i", 
latent  equals  2D,  and  the  sum  of  the  two,  or  total  hyper- 
metropia, =  3°. 

It  will  be  noticed  that  the  full  correction  (total  H.),  after 
the  paralysis  of  accommodation  has  passed  away,  will 
not  give  perfect  vision,  or  -|,  in  a  patient  under  forty  years 
of  age.  The  reason  is  obvious.  The  hypermetropia  is 
concealed  both  from  patient  and  physician  by  contraction 


MYOPIA.  57 

of  the  ciliary  muscle  before  instillation  of  the  mydriatic,  as 
well  as  after  its  effect  has  passed  away.  Hence  addition  of 
the  glass  correcting  latent  H,  unless  relaxation  of  the  muscle 
takes  place,  must  decrease  acuity  of  vision  by  rendering  the 
eye  artificially  myopic.  Persistent  wearing  of  the  correct- 
ing glasses  will  eventually  cause  the  latent  H.  to  become 
manifest,  and  visual  acuity  in  the  distance  will  thus  become 
normal. 

The  range  of  accommodation  in  hypermetropia  is  ex- 
pressed by  the  equation  a  =  p  -j-  r,  a  representing  accom- 
modation, /  the  near  point,  and  r  the  far  point.  To  the 

FIG.  30. 


MYOPIC  EYE. 


lens  which  equals  in  focal  distance  the  near  point  must  be 
added  the  lens  which  adapts  the  eye  to  parallel  instead  of 
converging  rays.  Thus,  if  /  =  20  cm.  (5°),  and  +  2  is 
needed  to  correct  total  H.,  Ace.  =  5°  +  2D  =  7°. 


MYOPIA. 

In  emmetropia,  it  will  be  remembered,  the  antero-posterior 
diameter  of  the  globe  is  of  such  length  that  parallel  rays 
of  light  come  to  a  focus  upon  the  retina,  and  that  in  hyper- 
metropia this  axis  of  the  ball  is  shorter,  and  parallel  rays 

tend  to  a  focus  behind  the  retina.     In  myopia,  the  antero- 
6 


58  A    MANUAL   OF    CLINICAL   OPHTHALMOLOGY. 

posterior  diameter  of  the  globe  is  longer  than  it  is  in 
emmetropia,  and  parallel  rays  are  focused  in  front  of  the 
retina.  In  the  myopic  eye,  therefore,  as  in  the  hyperme- 
tropic  eye,  the  retina  receives  only  circles  of  diffusion,  vary- 
ing in  extent  with  the  degree  of  the  myopia.  The  imme- 
diate cause  of  the  longer  axis  of  the  myopic  eye  is  found 
in  the  too  great  convexity  of  the  cornea  or  lens,  or  both, 
or  in  the  stretching  of  the  sclerotic  coat.  Myopia  is  con- 
genital or  acquired,  and  is  usually  progressive,  that  is  to 
say,  it  has  a  tendency  to  increase.  It  is  said  to  be  low  when 
the  myopia  is  3°  or  less  ;  moderate  in  the  degrees  between 
3  and  6D,  and  high  in  the  degrees  above  6D.  The  far  point 
of  a  myopic  eye  is  the  distal  limit  at  which  vision  equals 
that  of  an  emmetropic  eye,  and  the  near  point  \s,  the  approx- 
imate limit  at  which  the  retina  is  enabled  to  distinguish 
small  objects  (fine  print).  The  former  depends  on  the  degree 
of  the  myopia,  the  latter  on  the  power  of  accommodation. 
The  distance  between  the  far  and  near  points,  is  the  range 
of  accommodation,  and  is  expressed  a  =  p  —  r,  because 
the  lens  which  gives  full  acuity  of  V  for  distance  must  be 
subtracted  from  the  lens  whose  focal  length  equals  the  dis- 
tance of  the  near  point,  since  the  exercise  of  accommodation 
can  only  begin  at  the  far  point,  which  necessarily  lies  within 
infinity.  Thus,^  =  20  cm.  (5°),  r  =  50  cm.  (2°),  a  =  5  - 

2  =  3°. 

An  example  of  each  form  of  myopia  may  serve  to  fix 
the  differences  between  them  more  firmly  in  the  student's 
mind. 

Low  myopia. — Patient,  age  twenty,  complains  of  inability 
to  see  distant  objects  clearly.  No  asthenopia.  Has  never 
worn  glasses.  V.  in  each  eye  =  ^,  —  2D  in  trial  frame, 
gives  £ .  The  far  point  is  50  cm. ;  near  point,  8  cm.  Order 
full  correction  for  distance.  No  glass  for  near  is  required 


ASTIGMATISM.  59 

in  the  absence  of  astigmatism,  or  of  heterophoria  at  the  near 
point,  for  the  patient  reads  at  33  cm.  by  the  exercise  of  ID  of 
accommodation  and  3  meter  angles  of  convergence,  and  no 
symptoms  will  arise  from  the  use  of  the  unaided  eyes  in  near 
work,  unless  the  relative  accommodation  is  too  much  dis- 
turbed. 

Moderate  Myopia. — Patient,  age  twenty,  complains  of  bad 
vision  for  distance,  headache,  pain  in  eyes,  and  blurred  vision 
in  near  work,  caused  by  the  necessity  of  holding  the  work 
close  to  the  eyes,  which  strains  the  convergence,  and  this 
strain  quickly  induces  a  divergence  through  failure  of  con- 
vergence. V.,  in  each  eye,  ^  ;  — 6.D  in  trial  frame  gives  ^. 
Far  point,  16  cm.;  near  point,  practically  the  same.  The 
patient  does  not  require,  and,  therefore,  has  never  developed, 
accommodation.  The  correction  ordered  is,  for  far,  —  5-5OD  ; 
for  near,  —  3°.  This  correction  gives  far  point  at  33  cm.,  at 
which  distance  the  patient  can  comfortably  read.  For  dis- 
tance, less  than  the  full  correction  is  given,  to  avoid  dizzi- 
ness and  other  discomfort  from  apparent  diminution  in  size 
of  objects. 

High  Myopia. — Patient,  age  twenty,  vision  very  bad  for 
distance,  and  binocular  vision  for  reading  impossible.  The 
myopia  =  15°.  V.,  in  each  eye,  =  -^  ;  —  15°  =  ^-.  Full 
acuity  of  vision  cannot  be  obtained  on  account  of  organic 
changes  in  the  interior  of  the  eye  and  the  apparent  reduc- 
tion in  the  size  of  all  objects  seen  through  minus  glasses. 
Order,  —  12°  for  far,  and —  IOD  for  near.  Accommodation 
is  entirely  absent. 

ASTIGMATISM. 

ASTIGMATISM  is  that  condition  of  refraction  in  which  the 
curve  of  the  cornea  or  lens  or  both,  is  non-spherical,  and 
parallel  rays  of  light  entering  the  pupil  are  not  focused  to 


6o 


A    MANUAL   OF   CLINICAL  OPHTHALMOLOGY. 


a  point,  but  in  a  line.  Astigmatism  of  the  cornea  is  either 
regular  or  irregular ;  regular  when  the  two  principal  meri- 
dians are  at  right  angles  to  each  other  and  have  radii  of 
different  length,  and  irregular  when  the  corneal  curve,  as  a 
result  of  disease,  is  broken  by  a  number  of  irregularly 
defined  facets,  each  one  of  which  has  its  own  radius. 
Regular  astigmatism  is  hypermetropic,  myopic,  compound 
hypermetropic,  compound  myopic,  or  mixed. 

In  hypermetropic  astigmatism  one  principal  meridian  is  em- 
metropic  and  the  other  principal  meridian  at  right  angles  to 

FIG.  31. 


ACTION  OF  AN  ASTIGMATIC  SURFACE  ON  A  CONE  OF  LIGHT.     (Frost.} 

a,  t,  c,  rfis  the  astigmatic  surface:  diverging  rays  proceed  from  point_/^  and,  passing  through 
c  ft,  come  to  a  focus  at  ./>,  while  those  passing  through  a,  b  come  to  a  focus  at/2. 
'I  he  outline  of  the  cone  of  rays  a  f>,  c  d,  and/I?  varies,  as  shown  in  the  figure. 


it  is  hypermetropic;  in  myopic  astigmatism  one  meridian  is 
emmetropic,  and  the  meridian  at  right  angles  to  it,  myopic. 
Compound  hypermetropic  astigmatism  is  that  condition  in 
which  both  principal  meridians  are  hypermetropic,  one 
more  than  the  other ;  and  in  compound  myopic  astigmatism 
the  two  principal  meridians  are  myopic,  one  more  than  the 
other.  In  mixed  astigmatism  one  meridian  is  hyperme- 
tropic, and  the  other  meridian  at  right  angles  to  it, 
myopic. 

The  symptoms  of  astigmatism  are  defective  vision,  in- 


ASTIGMATISM.  6 1 

ability  to  use  the  eyes  in  prolonged  near  work,  pain  in  the 
eyeballs,  headache,  and  other  reflex  neuroses,  more  or  less 
obscure  and  ill-defined,  which  distract  the  patient  until  the 
ametropia  is  relieved  by  the  correcting  lens. 

Diagnosis  and  Treatment.  An  astigmatic  test-card,*  con- 
sisting of  exactly  similar  radiating  stripes  or  lines  (Fig.  32), 
is  placed  6  m.  from  the  patient,  who  is  directed  to  look  at 
them  and  tell  which  are  the  clearest  and  best  seen.  One  or 
two  of  these  radiating  lines  will  appear  to  be  brighter  and 
more  distinct  than  the  rest.  The  patient  is  hypermetropic  or 
myopic  for  the  dull  lines.  The  plus  or  minus  cylinder 
required  in  astigmatism  to  supplement  the  defective  refrac- 
tion of  the  hypermetropic  meridian,  or  to  diminish  the  myopic 
meridian,  is  placed  before  the  eye  with  its  axis  parallel  to 
the  faintest  lines.  When  the  lines  are  by  this  method  ren- 
dered equally  clear,  the  astigmatism  is  corrected.  In  com- 
pound hypermetropic  or  compound  myopic  astigmatism, 
the  apparent  inequality  of  the  lines  may  be  first  overcome  by 
a  cylinder,  and  the  remaining  hypermetropia  or  myopia  cor- 
rected by  a  plus  or  minus  spherical  lens,  or  if  the  spherical 
defect  is  so  marked  as  to  prevent  recognition  of  the  differ- 
ences in  the  lines  on  the  astigmatic  test-card,  a  part  or  all 
of  such  defect  may  be  corrected  by  a  spherical  lens,  and  a 
cylindrical  lens  used  to  correct  the  remaining  astigmatism. 
In  mixed  astigmatism  the  lines  will  appear  to  be  equally 
indistinct  at  6  m.,  when  the  hypermetropic  and  the  myopic 
meridians  are  defective  to  the  same  degree,  but  if  the  astig- 
matic card  is  brought  nearer  the  patient,  the  lines  in  the 
myopic  meridian  will  become  more  clear,  and  those  in  the 
hypermetropic  meridian  fainter.  A  minus  cylinder  will 


*  The  astigmatic  card  depicted  in  Fig.  32  was  recently  made,  at  our  request, 
by  Joseph  A.  Mullen,  and  may  be  obtained  from  J.  L.  Borsch  &  Co.,  1324 
Walnut  Street,  Philadelphia. 


62 


A    MANUAL   OF    CLINICAL   OPHTHALMOLOGY. 


correct  the  myopic,  and  a  plus  cylinder  the  hypermetropic, 
meridian.     The  two  cylinders  at  right  angles  to  each  other 

FIG.  32. 


ASTIGMATIC  CLOCK  FOR  TESTING  ASTIGMATISM. 


are  converted  into  a  sphero-cylinder,  which  the  patient  is 
instructed  to  wear.     For  example,  a  patient  sees  horizontal 


ASTIGMATISM.  63 

lines  best  at  I  m.  —  ic  ax.  180°  gives  normal  vision  for 
such  lines,  and  -|-  ic  ax.  90°  corrects  vertical  lines  at  6  m. 
The  formula  is:  —  ic  ax.  180°  O  +  ic  ax.  90°,  or, 
and  this  is  the  better  formula,  —  Is  o  -f  2C  ax.  90°. 

Following  are  illustrations  of  the  other  forms  of  astig- 
matism : — 

Hypermetropic  Astigmatism :  V.  =  -f ,  accommodation 
paralyzed;  horizontal  lines  seen  best;  -j-  Is  gives  vertical 
lines  best  without  increasing  acuity  of  vision,  and  — Is 
makes  vision  worse;  -f  i°  ax.  90°  renders  lines  equally  clear 
and  distinct  in  all  meridians  and  gives  -f. 

Myopic  Astigmatism  :  V.  =  f ,  vertical  lines  are  seen  best, 
-f-  Is  increases  dimness  of  lines  in  all  meridians.  —  Is  im- 
proves horizontal  and  dims  vertical  lines,  — ic  ax.  180°, 
brings  out  clearly  the  lines  in  defective  meridians,  and  gives 
normal  vision,  •£. 

Compound  Hypermetropic  Astigmatism  :  V.  =  -fy,  hori- 
zontal lines  seen  best  but  imperfectly,  -f-  Is  improves  lines 
in  all  meridians,  +  2s  over-corrects  lines  on  the  horizontal 
axis  +  Is  O  -j-  i°  ax.  90°,  gives  the  appearance  of  equal- 
ity to  all  lines,  and  vision  is  increased  to  -|. 

Compound  Myopic  Astigmatism :  V.  =  -f% ;  all  lines  in- 
distinct and  acuity  of  vision  too  low  to  discriminate  differ- 
ences in  them ;  —  2s  improves  all  lines,  and  renders  the 
vertical  lines  normal  in  outline  and  color;  —  I8  added 
brings  out  the  horizontal,  and  dims  the  vertical  lines. 
Hence  a  stronger  minus  glass  is  required  for  the  horizontal 
than  for  the  vertical  meridian.  The  formula,  —  2s  o  —  ic 
ax.  1 80°  makes  all  lines  appear  equal,  and  gives  |-. 

Irregular  Astigmatism  cannot  be  corrected,  but  an  exam- 
ination of  the  refraction  will  not  infrequently  reveal  an 
underlying  spherical  or  astigmatic  defect,  the  correction  of 
which  will  greatly  improve  vision. 


64 


A    MANUAL   OF    CLINICAL   OPHTHALMOLOGY. 


EXAMINATION  BY  THE  OPHTHALMOSCOPE. 

The  refraction  ophthalmoscope  (Fig.  33)  consists  of  a  rect- 
angular or  round  concave  mirror  perforated  in  its  centre 
by  a  circular  opening  4  mm.  in  diameter.  Immediately 
back  of  the  mirror  is  one  or  more  metal  discs  in  which  is 
placed  a  number  of  lenses,  plus  ID  to  20°  and  minus 
ID  to  2OD,  somewhat  larger  than  the  opening  in  the  mirror, 


FIG.   33. 


MORTON'S  OPHTHALMOSCOPE. 


any  one  of  which  is  made  by  a  simple  mechanical  device 
to  rotate  in  position  behind  the  opening. 

In  the  direct  examination  by  the  ophthalmoscope,  the 
patient  is  placed  about  50  cm.  from,  and  with  his  back  to, 
the  light,  which  should  be  drawn  to  the  side  of,  and  on  a 
level  with,  the  eye  under  observation.  To  examine  the 
right  eye,  the  observer  holds  the  ophthalmoscope  in  his 


EXAMINATION    BY   THE   OPHTHALMOSCOPE.  65 

right  hand  and  in  front  of  his  right  eye.  Looking  through 
the  opening  in  the  mirror  at  some  little  distance  from 
the  patient,  whose  eye  is  illuminated  by  reflection  of  light 
from  the  mirror,  the  observer  sees  a  red  reflex  through 
the  pupil,  the  reflection  from  the  choroid  of  the  light 
thrown  by  the  mirror  into  the  patient's  eye.  The  outlines 


THE  ENTRANCE  OF  THE  OPTIC   NERVE  WITH  THE  ADJACENT   PARTS  OF 
THE  FUNDUS  OF  THE  NORMAL  EYE. 

A.  Physiological  excavation,  b,  Choroidal  ring.  c.  Arteries,  d.  Veins,  g.  Division  of 
the  central  artery.  A.  Division  of  the  central  vein.  L.  Lamina  cribrosa.  t.  Tem- 
poral (outer)  side.  «.  Nasal  (inner)  side. 


of  the  majority  of  the  choroidal  vessels  are  concealed  by 
the  pigment  coat  of  the  retina,  and  only  a  glare  is  seen. 
Approaching  the  eye  as  closely  as  possible,  without  chang- 
ing the  refraction  of  the  ophthalmoscope,  the  vessels  of  the 
retina  are  displayed,  leading  to  and  from  the  optic  disc  or 


66  A    MANUAL   OF   CLINICAL  OPHTHALMOLOGY. 

papilla  (Fig.  34),  which  appears  as  a  pinkish-white  round 
or  oval  disc,  slightly  excavated  in  its  centre.  Only  a  small 
portion  of  the  fundus  can  be  seen  at  once,  but  to  the  ob- 
server, standing  in  close  proximity  to  the  patient,  the  field 
covered  is  apparently  large,  the  details  being  magnified 
about  fourfold.  The  principal  points  to  be  observed  and 
noted,  are  the  condition  of  the  media,  shape  of  disc, 
the  distinctness  of  its  marginal  outlines,  character  and  de- 
gree of  excavation,  pulsation  of  veins  or  arteries,  presence 
or  absence  of  pigment  spots,  calibre  of  vessels,  and  dis- 
turbances in  their  coats.  The  fovea  is  removed  about  four 
times  the  apparent  diameter  of  the  disc  to  the  temporal  side 
of  the  nerve,  and  appears  as  a  rounded  red  spot  with  a  bright, 
glistening  centre,  round  or  oval,  and  inclined  to  modify  its 
shape  according  to  the  amount,  intensity,  and  direction  of 
the  light  thrown  upon  it.  The  fovea  is  free  from  visible 
blood-vessels.  Each  part  of  the  fundus  should  be  observed 
in  turn :  first,  the  nerve  and  adjacent  parts,  then  the 
fovea,  and  finally  the  different  quadrants  or  sections  of  the 
fundus.  This  is  readily  accomplished  by  having  the  patient 
rotate  the  eye  in  different  directions.  It  is  good  practice 
in  all  ophthalmoscopic  observations,  to  examine  first  the 
cornea,  using  +  6D  in  ophth.  for  this  purpose,  secondly, 
the  pupil  and  lens  with  -f-  5°  and  the  anterior  and  pos- 
terior portions  of  the  vitreous  with  -f-  3s,  before  proceed- 
ing to  the  details  of  the  fundus. 

By  the  indirect  method  the  light  is  thrown  by  the  mirror 
through  a  lens  of  13°  into  the  patient's  eye.  The  light, 
returning  through  the  lens,  is  focused  at  approximately 
its  focal  distance.  Before  the  opening  in  the  mirror  is 
-|-  4D,  to  enlarge  the  aerial  image  and  to  replace  the 
observer's  strain  of  accommodation.  This  method  is 


EXAMINATION    BY   THE    OPHTHALMOSCOPE.  67 

especially  useful  in  determining  the  condition  of  the 
choroid  and  retina  in  high  myopia  and  in  opacities  of 
the  media. 

To  determine  refraction  by  the  ophthalmoscope  by  the 
direct  method,  theoretically,  the  observer's  eye  should 
be  emmetropic  and  at  rest,  and  the  accommodation  of 
the  eye  examined  in  abeyance.  The  mirror  with  the 
observing  eye  immediately  back  of  it,  is  held  within 
half  an  inch  of  the  eye  observed.  The  media  are  clear. 
If  observed  and  observing  eyes  are  emmetropic,  rays 
passing  from  each  point  of  the  fundus  of  the  former 
become  parallel  as  they  emerge  out  of  the  cornea,  and, 
entering  the  cornea  of  the  latter  parallel,  are  focused  upon 
the  observer's  retina.  If  the  patient  is  hypermetropic,  ob- 
server emmetropic,  the  rays  emerging  from  his  cornea  are 
divergent,  details  indistinct,  and  a  plus  glass  will  be  re- 
quired to  so  bend  the  rays  that  they  enter  observer's  eye 
parallel,  and  this  is  done  by  rotating  the  metal  disc  in  the 
ophthalmoscope  until  the  glass  required  to  clear  the  picture 
comes  in  position  behind  the  mirror.  If  the  patient  is 
myopic,  observer  emmetropic,  the  rays  emerging  out  of  his 
cornea  are  convergent,  and  a  minus  glass  will  be  required 
to  render  them  parallel  as  they  enter  the  observer's  eye. 
In  both  instances  the  observer  is  aware,  by  the  dim  images 
of  the  small  vessels  near  the  fovea,  where  only  an  accurate 
determination  may  be  made,  that  the  rays  from  this  region 
are  not  entering  his  eye  parallel,  but  from  this  knowledge 
alone  he  cannot  tell  whether  they  are  converging  or 
diverging.  He  revolves  the  disc  until  he  finds  a  glass 
which  defines  the  image,  and  that  glass  is  the  measure 
of  the  ametropia  of  the  observed  eye. 

In  simple  astigmatism  the  vessels  in  one  meridian  will  be 
seen   more    clearly   defined    than   those    of    the   opposite 


68  A    MANUAL   OF   CLINICAL   OPHTHALMOLOGY. 

meridian,  and  the  spherical  lens,  plus  or  minus,  which 
makes  those  vessels  clear  and  blurs  the  opposite  ones,  will 
designate  the  degree,  kind  and  axis  of  the  astigmatism.  In 
compound  astigmatism,  vessels  in  all  meridians  arc  indis- 
tinct, some  more  than  others.  The  glass,  plus  or  minus, 
which  makes  each  set  of  vessels  in  turn  clear  and  distinct, 
will  be  the  kind  and  degree  of  ametropia  for  these  meri- 
dians. The  disc  is  usually  oblong,  its  long  diameter 
corresponding  with  the  axis  of  the  astigmatism. 

Diagnosis  of  Hypermetropia  by  the  Ophthalmoscope. — The 
retinal  vessels  are  seen  at  several  inches  from  the  observed 
eye,  and  apparently  move  in  the  same  direction  as  the  mirror. 
More  details  are  evident  on  closer  approximation  of  the  oph- 
thalmoscope. The  nerve  and  vessels  are  distinctly  seen 
without  a  lens,  but  they  can  also  be  seen  tJirough  a  conrc.v 
glass..  The  first,  by  overcoming  the  divergence  of  rays 
emerging  from  observed  eye  by  contraction  of  the  ciliary 
muscle  in  observing  eye,  and  the  latter,  by  relaxation  of 
the  contraction,  and  substitution  of  a  convex  glass  for  it. 
The  disc  is  apparently  smaller  than  in  emmetropia  or 
myopia. 

The  Diagnosis  of  Myopia  by  the  Ophthalmoscope. — The  disc 
is  large,  but  ill  defined,  and  can  be  distinctly  seen  only  through 
a  minus  glass  and  on  close  approximation.  In  high  de- 
grees of  myopia,  8D  or  more,  an  aerial  inverted  image  of  a 
small  part  of  the  fundus  may  be  seen  at  a  distance  of  five 
inches  or  less.  The  image  is  inverted,  and  vessels,  there- 
fore, move  in  an  opposite  direction  to  that  of  the  mirror. 

An  accurate  estimation  of  the  degree  of  the  ametropia  is 
rarely  attained,  but  an  approximate  estimate  is  always  made 
by  the  experienced  ophthalmoscopist. 


FIG.  35. 


ILLUSTRATION  OF  RETINOSCOPY  BY  THE  PLANE  MIRROR. 

1.  L.  Source  of  illumination.     M.  Mirror.     /.  Inverted  image  of  L  on  retina.     /.  Apparent 

source  of  illumination.     If  the  mirror  be  rotated  to  M':  I'   New  position  of  L  on  retina. 
/'.  New  apparent  position  of  L.     Hence  the  shadow  has  moved  with  mirror. 

2.  Myopic  eye,  producing  an  inverted  aerial  image,  since  the  rays  coming  out  from  the  eye 

cross  between  the  cornea  and  mirror. 

69 


7O  A    MANUAL   OF   CLINICAL  OPHTHALMOLOGY. 

RETINOSCOPY  BY    THE    PLANE    MIRROR. 

The  observer  stands  I  m.  in  front  of  the  patient,  behind 
and  slightly  above  whose  head  a  small,  bright  light  is 
placed.  The  mirror  reflects  parallel  rays  of  light  into 
patient's  eye,  and  the  rays  return  out  of  it  parallel 
(emmetropia),  diverging  (hypermetropia),  or  converging 
(myopia).  In  an  cmmctropic  eye,  the  image  of  the  flame 
on  patient's  retina  moves  with  the  movement  of  the 
mirror  in  all  meridians.  If  -f  3"  is  placed  in  spectacle 
frame  before  the  patient's  eye,  the  rays  emerging  out  of 
which  are  parallel,  they  will  be  brought  to  a  point  at  the 
focal  distance  of  the  lens,  33  cm.,  the /#/>//  of  reversal,  as  it 
is  called.  The  point  of  reversal  is  determined  by  the  ob- 
server, who  gradually  approaches  the  patient,  rotating 
the  mirror  until  he  notices  that  the  light  or  shadow  in  the 
patient's  eye  ceases  to  move  against  it.  No  movement  of 
the  light  is  noticed  exactly  at  the  point  of  reversal,  but 
nearer  the  patient's  face,  or  within  the  focal  distance  of  the 
lens,  the  light  will  move  in  the  same  direction  as  the  move- 
ment of  the  mirron  All  meridians  of  the  cornea  must  be 
examined,  and  in  each  axis  the  point  of  reversal  will  be 
found  at  33  cm.  from  the  patient's  eye. 

In  hypermetropia  t  the  shadow  moves  with  the  mirror.  Use 
-f  3  lens  as  in  the  previous  case.  If  the  point  of  reversal  is 
I  m.  from  the  patient's  eye,  there  must  be  2D  of  hyperme- 
tropia. The  -j-  3"  corrects  all  the  hypermetropia  and  pro- 
duces i°  of  artificial  myopia,  the  far  point  of  which  is  I  m. 
(The  rays  enter  the  lens  diverging  from  the  patient's  eye,  are 
brought  to  a  focus  at  I  m.,  hence  the  -f  3"  over-corrects  the 
defect  by  in.)  If  no  point  of  reversal  can  be  determined  by 
-f  3"  at  I  m.,  the  hypermetropia  exceeds  2",  and  a  stronger 
lens  will  be  required.  Suppose  we  place  -f  5°  in  spectacle 


RETINOSCOPY    BY    THE    PLANE    MIRROR.  /I 

frame,  and  find  that  the  point  of  reversal  is  at  50  cm., 
which  is  the  far  point  of  2D  of  myopia,  the  hypermetropia 
will,  in  this  case,  equal  3",  the  +  5"  having  over-corrected 
the  defect  by  2D. 

In  myopia,  the  shadow  moves  in  the  opposite  direction  to 
the  movements  of  the  mirror.  No  lens  is  necessary  unless 
the  defect  is  less  than  ID.  The  point  of  reversal  will  be 
found  at  the  far  point  of  the  eye,  and  the  distance  between 
this  point  and  the  eye  equals  the  refracting  power  of  the 
excess  of  curvature  in  the  eye.  Thus,  if  the  far  point  is  40 
cm.,  the  myopia  equals  2.50°;  if  at  33  cm.,  the  myopia 
equals  3",  or,  if  at  25  cm.,  the  myopia  equals  4".  If  the 
far  point  cannot  be  found  at  25  cm.,  or  farther,  and  if  the 
shadows  continue  to  move  opposite  to  the  mirror  at  25  cm., 
myopia  of  more  than  4°  is  assured.  Closer  than  this,  an 
inaccurate  estimate  of  the  point  of  reversal,  when  the 
shadows  cease  to  move  against,  and  begin  to  move  with  the 
mirror,  causes  a  considerable  error  in  the  result,  and  to  avoid 
error  it  is  best,  under  these  conditions,  to  disperse  the  rays 
by  placing  a  minus  glass  in  spectacle  frame.  The  lens  used 
for  this  purpose  must  be  added  to  the  myopia  determined  by 
its  use.  For  example,  if,  with  —  3°  held  in  trial  frames  the 
point  of  reversal  is  found  to  be  at  50  cm.,  the  myopia  =  5°. 

HYPERMETROPIC  AND  MYOPIC  ASTIGMATISM  are  de- 
termined by  the  method  employed  in  spherical  defects, 
and  are  not  more  difficult.  The  point  of  reversal  is  found 
to  be  at  different  distances  for  the  two  principal  meridians. 
For  example,  with  -f-  3°  point  of  reversal  for  horizonal 
meridian  is  at  I  m.,  and  for  vertical  meridian  33  cm.,  the 
hypermetropic  astigmatism  is  equal  to  2D  ax.  90°.  Or 
suppose  with  -f-  5D  the  point  of  reversal  for  horizontal 
meridian  is  at  50  cm.,  H  =  3"  ax.  90°,  and  at  33  cm.,  for 
vertical  meridian  H  =  2D  ax.  180°,  it  must  be  evident  that 


72  A    MANUAL  OF   CLINICAL  OPHTHALMOLOGY. 

there  is  compound  hypermetropic  astigmatism,  equal  to 
+  2*  o  -f-  ic  ax.  90°.  If  without  a  lens,  the  point  of 
reversal  for  vertical  meridian  is  at  33  cm.,  the  myopia 
will  equal  3"  for  that  meridian.  With  -f  I  the  point  of 
reversal  for  horizontal  meridian  is  at  I  m.  ;  that  meridian  is 
emmetropic.  Glasses  for  this  case  should  be, —  3°  ax.  180°. 
Again,  suppose  that  without  a  glass  point  of  reversal  for 
axis  45°  (meridian  opposite)  =  50  cm.  (myopia  =  2D  ax. 
45°),  with  -\-  4D  in  spectacle  frames  for  axis  135°  (meridian 
opposite)  =  50  cm.  (hypermetropia  2"  ax.  135°),  the  cor- 
rection will  be,  --  2s  O  -f-  4C  ax.  135°.  In  conducting 
examinations  by  retinoscopy  the  patient's  pupil  should 
be  dilated. 

This  method  of  determining  the  refraction  is  accurate, 
rapid,  scientific,  and  especially  valuable  in  children  and 
illiterate  persons,  and  in  the  diagnosis  of  irregular  cornea 
without  opacities. 

PRESBYOPIA. 

PRESBYOPIA  (P)  is  a  failure  of  accommodation  due  to 
senile  changes,  and  is  manifested  by  a  recedence  of  the  near 
point.  It  is  not  a  disease,  it  is  not  an  error  of  refraction, 
but  a  loss  of  elasticity  of  the  crystalline  lens,  or  of  power 
in  the  ciliary  muscle,  or  the  two  combined.  Greater  stress 
should  be  laid  on  the  former. 

Presbyopia  in  emmctropia,  begins  to  manifest  itself  at  or 
about  the  age  of  45  years,  the  subject  noticing  that  small 
objects,  print,  cannot  be  comfortably  or  distinctly  seen  for 
any  length  of  time  at  the  usual  reading  distance,  35  cm., 
and  is  obliged  to  hold  the  book,  paper,  or  sewing  farther 
from  the  eye  than  formerly.  Continuous  reading  induces 
blurring,  pain,  headache,  lacrymation,  etc.  A  glass  which 
will  bring  the  near  point  closer  to  the  eye,  and  thus  diminish 


PRESBYOPIA.  73 

the  effort  to  focus  small  objects  at  35  cm.,  in  which  there  is 
an  obligation  to  call  too  much  on  the  reserve  accommoda- 
tion, is  required.  About  the  age  of  45  years,  the  near  point 
=  20  cm.,  the  reading  distance  33  cm.,  and  the  reserve 
accommodation  =  2D.  At  this  age,  therefore,  an  emme- 
tropic  person  must  exercise  in  near  work  all  but  2D  of 
accommodation.  With  -f-  ID,  the  near  point  is  brought 
back  to  16  cm.,  and  he  thus  has  for  33  cm.,  3°  of  accommo- 
dation in  reserve.  At  50  years  the  near  point  has  receded  to 
25  cm.,  and  the  total  accommodation  equals  4°,  and  -f  2  D 
brings  near  point  to  16  cm.  and  patient  reads  comfortably  at 
33  cm.  with  3°  of  accommodation  in  reserve.  At  a  more 
advanced  age,  accommodation  has  entirely  failed  and  must 
be  substituted  by  a  plus  glass  which  has  a  focus  at  a  con- 
venient distance  for  close  work.  Patients  differ  in  showing 
signs  of  advancing  age,  and  no  law  governing  increase 
of  glass  can  be  laid  down  as  unalterable,  but  the  above 
changes  represent  the  average  of  cases,  and  must  be  modi- 
fied to  meet  individual  necessities. 

Presbyopia  in  hypcrmetropia  and  in  compound  Jiypcrme- 
tropic  astigmatism.  The  convex  lens  necessary  to  restore 
the  receded  near  point,  must  be  determined  exactly  as  in 
emmetropia,  and  added  to  the  correction  of  existing  hyper- 
metropia  or  compound  hypermetropic  astigmatism.  For 
example,  -f-  2D  =  -|  in  a  patient,  age  50,  near  point 
(with  +  2"  )  =  25  cm.  By  adding  -f  i.5OD,  the  near 
point  =  1 8  cm.;  -f  2D  is  ordered  for  distance,  and  -f  3-5° 
for  near.  Another  case  :  Patient,  age  45,  -f-  1s  o  +  2°  ax. 
90°  =  f-,  which  is  ordered  for  distance,  and  -f-  2  o  +  2C 
ax.  90°  for  near. 

Presbyopia  in  Myopia,  and  Compound  Myopic  Astigmatism. 
The  presbyopic  correction  in  higher  grades  of  myopia 
must  be  made  at  a  much  earlier  age  than  in  emmetropia  or 
7 


74 


A    MANUAL   OF    CLINICAL   OPHTHALMOLOGY. 


hypermetropia,  on  account  of  the  natural  feebleness  from 
non-development  of  the  ciliary  muscle.  Example:  —  2D  = 
£.  No  glass  will  be  required  for  near  work  until  patient 
has  reached  forty-five  to  fifty  years,  because  he  has  used 
but  ID  of  accommodation  for  reading  at  33  cm.  After  that 
age  plus  glasses  must  be  added,  accommodation  having 

FIG.  36. 
A. 


15  14    13  12  11   10    9    87654    3    2  IDoolD  !i    3  * 

E.   .M5 

Acc=i2o.  ;      _l  I  I  I  I  !  i 

M.'iD.  ••1r 
Acc?120. 
H.3Q.aetJ5. 
Acc=12D. 


rr    - H- 


E.aeUO 
AccT4-5D. 


E.  eet.50. 
Acc=2-5D. 


M.3D.at.50. 
.Acc=2-5D. 


H.3D.ath.4Q 
Acc?4-5D. 


H.3D.aet50 
Acc?2-5D. 


DIAGRAMS  OF  RANGE  OF  ACCOMMODATION  IN  E.,  H.  AND  M. 

A.  Patient  aged  15.     B.    From  40  to  50  years. 


commenced  to  fail.  At  sixty,  —  2°  for  far,  and  +  1-50"  for 
near  vision.  Patient,  age  forty-five,  requiring  —  8  O  — 
2C  ax.  1 80°  for  distance,  will  wear  —  5  o  —  2r  ax.  180° 
for  near.  Take,  as  an  example,  next,  simple  myopic  astig- 
matism :  — 2C  ax.  135°  =  f,  in  a  patient  forty-five  years  old, 


MYDRIATICS.  75 

the  presbyopia  correction  is  -J-  I  o  —  2C  ax.  135°.  At  the 
age  of  fifty,  the  correction  would  be  -f  2  O  —  2.c  ax.  135° 
(=  +  2cax.450). 

Presbyopia  in  mixed  astigmatism  :  age  forty-five,  — I  o  -f- 
3°  ax.  90°  =  f.  Add  -\-  I-  f°r  near,  which  would  give 
as  the  presbyopic  correction  +  3°  ax.  90°  (+  I  added  to 
—  i  =  o)  ;  at  fifty,  add  +  2D  for  near,  which  would  equal  -f 
i  o  -\~  3°  ax.  90°. 

In  all  cases  of  presbyopia  the  weakest  glass  which  will 
serve  all  the  purposes  demanded  should  be  ordered,  for  it 
must  be  remembered  that  the  ciliary  muscle  and  internal 
rectus  are  supplied  by  the  same  nerve,  and  that  a  strong 
glass  enforces  excessive  convergence. 


MYDRIATICS. 

In  estimating  total  hypermetropia  or  hypermetropic 
astigmatism,  and  especially  those  of  minor  degree,  it  will 
be  necessary  to  paralyze  the  accommodation  in  most 
persons  under  forty  years  of  age.  After  that  age  the  accom- 
modation is  so  limited  that  it  may  be  dispensed  with  as  an 
important  factor  in  the  correction  of  ametropia.  Contra- 
indication to  the  use  of  a  mydriatic  in  a  patient  more  than 
forty  years  of  age,  is  based  on  the  fact  that  its  employment 
may  precipitate  an  attack  of  acute  glaucoma  in  an  eye  pre- 
disposed to  that  disease.  In  persons  less  than  forty  years 
old,  this  disease  is  rarely  encountered.  Moreover,  after 
that  time  of  life  the  accommodation  has  become  relaxed  to 
such  an  extent  that  paralysis  is  not  only  unnecessary  but  a 
positive  hindrance,  since  it  is  desirable  in  most  cases  of  this 
nature  to  estimate  the  range  of  accommodation  and  pre- 
scribe glasses  for  near  work,  and  this  cannot  be  accurately 
done  during  paralysis. 


76  A    MANUAL   OF   CLINICAL   OPHTHALMOLOGY. 

In  low  degrees  of  myopia  and  myopic  astigmatism  in 
young  persons,  abolition  of  the  accommodation  is  necessary, 
because  contraction  of  the  ciliary  muscle  increases  the 
defect,  and  a  glass  ordered  without  mydriasis  would  over- 
correct  the  error. 

Spasm  of  Accommodation,  which  is  frequently  present  in 
low  degrees  of  hypermetropia  or  hypermetropic  astig- 
matism, simulating  myopia,  cannot  be  corrected  without 
mydriasis.  The  patient  should  be  informed  that  vision 
will  be  temporarily  disturbed  by  the  mydriatic,  and  that 
near  work  will  not  be  possible  during  the  continuance  of 
its  action.  The  patient  should  also  be  told  of  the  possible 
constitutional  effects,  such  as  flushing  of  the  face,  dry 
throat,  dizziness,  drowsiness,  and,  in  rare  instances,  active 
delirium. 

Mydriatics  are  sometimes  very  useful  in  discriminating 
nervous  symptoms  due  to  eye  strain,  headache,  chorea,  and 
other  reflex  disturbances  of  function,  from  those  due  to 
other  causes.  During  paralysis  of  accommodation,  should 
they  be  due  to  overaction  of  the  ciliary,  or  extrinsic  ocular 
muscles,  they  will  be  modified  or  entirely  subdued,  to  re- 
turn when  the  mydriasis  has  passed  away.  When  the 
symptoms  are  due  to  organic  lesions,  or  disease  of  other 
organs,  they  are  not  affected  by  paralysis  of  accommoda- 
tion. 

Atropine  sulphate  (gr.  iv-5j),  duboisine  sulphate  (gr.  ij 
— 5j),  hyoscyamine  sulphate  (gr.  ij-Sj),  and  hydrobro- 
mate  of  homatropine  (gr.  viij-5j),  are  the  mydriatics 
employed  for  the  purposes  thus  indicated,  as  well  as  in 
certain  inflammatory  conditions  of  the  eye  to  secure  rest  of 
the  organ,  and  to  prevent  adhesions  between  the  iris  and 
lens  capsule,  or  between  the  iris  and  cornea. 

For  determining  refraction,  duboisine  is  to  be  preferred  to 


MYDRIATICS.  77 

other  members  of  the  group.  It  acts  more  rapidly,  and  the 
effects  pass  away  sooner,  than  atropine ;  and  as  compared 
with  hyoscyamine  and  homatropine,  the  mydriasis  is  more 
complete,  when  induced  by  one  or  two  instillations  of  the 
drug.  Atropine  is  indicated  in  disease.  To  dilate  the 
pupil  for  the  purpose  of  examining  the  eye  ground 
homatropine  is  probably  the  best  agent,  its  action  being 
rapid  and  transient. 

The  hydrobromate  of  cocaine  (4  per  cent,  sol.)  dilates 
the  pupil  and  partly  paralyzes  the  accommodation,  and 
should,  therefore,  be  classed  among  the  mydriatics.  It  is, 
however,  useless  as  a  mydriatic,  because  it  destroys  the 
epithelium  of  the  cornea  and  clouds  its  transparency.  In 
ophthalmic  practice  it  is  only  used  to  induce  local  anaes- 
thesia, or  as  an  adjunct  to  other  mydriatics  to  secure  the 
widest  possible  dilatation  of  the  pupil. 


PART  IV. 

THE  OCULAR  MUSCLES. 

The  action  of  the  muscles  upon  the  eyeball  should  be 
considered,  first,  in  respect  of  the  change  of  position  of  the 
cornea ;  and,  secondly,  of  the  change  of  position  of  the 
vertical  meridian  of  the  cornea. 

The  external  rectus  rolls  the  cornea  outward,  the  inter- 
nal rectus  inward,  the  superior  rectus  upward  and  inward, 
the  upper  end  of  the  meridian  turning  inward,  and 
the  inferior  rectus  rolls  the  cornea  downward  and  in- 
ward, turning  the  upper  end  of  the  meridian  outward.  The 
superior  oblique  muscle  rolls  the  cornea  downward  and 
outward,  turning  the  upper  end  of  the  meridian  inward, 
and  the  inferior  oblique  rolls  it  upward  and  outward,  rota- 
ting the  upper  end  of  the  meridian  outward. 

The  globe  is  rolled  outward  by  the  combined  action  of 
the  external  rectus  and  the  two  oblique  muscles ;  inward 
by  the  internal,  superior,  and  inferior  recti ;  ufnvard  by  the 
superior  rectus  and  inferior  oblique,  and  dim' meant  by 
the  inferior  rectus  and  superior  oblique.  (Fig.  37).  The 
muscular  apparatus  of  the  two  eyes  are  in  intimate  asso- 
ciation, have  a  concerted  action,  and  are  stimulated  by  a 
common  nervous  impulse. 

PARALYSIS. 

In  paralysis  of  an  ocular  muscle,  the  symptoms  are 
marked  and  significant.  There  is  double  vision  (diplopia) 
with  limited  movement  of  affected  eye  on  the  side  and  in  the 

78 


PARALYSIS. 


79 


direction  of  the  paralyzed  muscle,  and  secondary  squint,  or 
corresponding  deviation  of  the  sound  eye,  when  fixing  with 
the  affected  eye.  The  head  is  disposed  toward  the  paralyzed 
side,  and  the  eye  has  a  tendency  to  close.  Dizziness,  con- 
fusion, and  incorrect  estimation  of  position  and  of  space, 

FIG.  37. 


SCHEME  OF  THE  ACTION  OF  THE  OCULAR  MUSCLES. 

Q  E.  Direction  of  traction  of  ext.  rect.  Qi,  I.  Of  int.  reel.  Si.  Of  sup.  and  inf.  recti. 
ab.  Of  inf.  oblique,  c  d.  Of  sup.  oblique.  O.  Point  of  rotation.  Q  Qj.  Transverse 
axis. 

are  occasional  symptoms.  The  two  images  of  a  single 
object  seen  in  the  median  line  are  more  widely  separated 
when  the  object  is  moved  in  the  direction  of  the  action  of 
the  paralyzed  muscle.  The  true  image  is  seen  by  the  sound, 


8o 


A    MANUAL  OF  CLINICAL  OPHTHALMOLOGY. 


and  the  false  image  by  the  affected,  eye.  To  determine  the 
eye  and  muscle  affected,  the  position  of  the  images  and  the 
changing  relation  between  them,  induced  by  the  move- 
ment of  head  and  object  looked  at,  must  be  studied.  It 
may  be  stated  in  general  terms  that,  first,  the  image  is  false, 
and  belongs  to  the  affected  eye,  which,  in  the  region  of 


FIG.  38. 


diplopia,  moves  faster  than  the  moving  object;  second, 
that  in  pathological  convergence  homonymous  (image  on 
same  side  as  the  eye),  and  in  pathological  divergence,  hctcr- 
onymous  (image  on  side  opposite  to  eye),  diplopia  is  found  ; 
and,  third,  the  false  image  stands  in  such  relation  to  the 
affected  eye  as  the  paralyzed  muscle  normally  functionates. 


PARALYSIS. 


8l 


In  paralysis  of  the  external  reclu s  (Fig.  38)  the  diplopia  is 
homonymous  (not  crossed),  and  the  images  are  not  tilted 
at  either  end.  In  paralysis  of  the  internal  rectus  (Fig.  39) 
the  diplopia  is,  conversely,  heteronymous  (crossed),  and  the 
false  image  is  not  tilted  at  either  extremity.  The  diplopia 
is  crossed  opposite  the  affected  muscle  in  paralysis  of  the 

FIG.  39. 


ob.  Object.     Fob.  Apparent  position  of  object  seen  by  right  eye. 

superior  rectus,  and  the  upper  end  of  the  false  image 
is  tilted  slightly  inward.  The  diplopia  is  also  crossed  in 
paralysis  of  the  inferior  rectus,  the  upper  end  of  the  false 
image  tilting  slightly  outward.  There  is  homonymous 
diplopia  in  paralysis  of  the  superior  and  inferior  oblique ; 


82  A    MANUAL   OF  CLINICAL   OPHTHALMOLOGY. 

in  the  former  case  the  upper  end  of  the  false  image  is* 
tilted  inward,  and  in  the  latter  outward. 

The  position  of  the  images  is  modified  when  more  than 
one  muscle  is  paralyzed,  and  the  diagnosis  is,  under  these 
conditions,  not  infrequently  obscure. 

OPHTHALMOPLEGIA  is  the  name  given  to  designate  paraly- 
sis of  all  the  muscles  of  the  eye.  Ophthalmoplegia  externa 
is  an  occasional  symptom  of  locomotor  ataxia.  Ophthal- 
moplegia interna  is  very  rare,  but  paralysis  of  accommo- 
dation, or  partial  Ophthalmoplegia  interna,  is  a  common 
sequence  of  diphtheria. 

The  affection  may  be  caused  by  syphilis,  rheumatism, 
traumatism,  tumors,  hydrocephalus,  diphtheria,  meningitis, 
spinal  affections,  and  by  basal,  cortical,  or  nuclear  disease. 

Prognosis  is  good  in  syphilis,  rheumatism,  and  diph- 
theria, and  grave  in  organic  disease  of  the  brain,  nerve, 
or  spinal  cord. 

Treatment  is  medical  or  electrical,  and  is  primarily  ad- 
dressed to  the  cause  of  paralysis.  Operative  interference 
is  not  warranted. 

NYSTAGMUS  is  an  involuntary  oscillation  of  the  eyeball, 
due  to  the  instantaneous  contraction  and  relaxation  of  one 
or  more  muscles  from  defective  co-ordination.  It  is  con- 
genital in  microphthalmus,  coloboma,  certain  forms  of 
congenital  cataract,  albinos,  and  in  Friederich's  disease.  It 
is  present,  sometimes,  in  lesions  of  transparency  due  to 
ophthalmia  neonatorum,  and  in  retinitis  pigmentosa. 
Miners  who  are  compelled  to  work  for  long  periods  of 
time  in  strained  positions,  and  in  darkness,  frequently 
develop  the  disease.  Internal  squint  is  a  frequent  compli- 
cation of  nystagmus. 

The  prognosis  is  never  encouraging  under  the  most 
favorable  circumstances,  but  the  vision,  which  is  usually 


FUNCTIONAL    MUSCULAR    AFFECTIONS.  83 

defective,  may  be  improved  by  glasses,  the  squint  cured  by 
operation,  and  some  relief  from  the  more  distressing  symp- 
toms obtained  by  these  means  in  cases  of  recent  duration. 
No  further  relief  has  been  hitherto  accomplished. 


FUNCTIONAL  MUSCULAR  AFFECTIONS. 

In  muscular  anomalies  of  a  functional  character,  there 
is  a  deviation,  or  a  tendency  to  deviation,  of  the  eyes  from 
equilibrium. 

Accepting  Stephens'  nomenclature,  which  is  accurately 
descriptive  and  scientific,  the  different  muscular  anomalies 
are  defined  as  follows  : — Ortliophoria,  perfect  binocular  equi- 
librium ;  Heterophoria,  imperfect  binocular  equilibrium ; 
Hyperplioria,  a  tendency  of  one  eye  to  deviate  upward ; 
Esophoria,  a  tendency  to  deviate  inward  ;  Exophoria,  a 
tendency  to  deviate  outward ;  Hyperesophoria,  a  tendency 
to  deviate  upward  and  inward  of  one  eye,  or  downward 
and  inward  of  the  other  ;  Hyperexophoria,  a  tendency  to 
deviate  upward  and  outward  of  one,  or  downward  and 
outward  of  the  other,  eye. 

It  must  be  borne  in  mind  that  functional  deviations  in- 
volve both  eyes.  One  eye  alone  cannot  be  at  fault  in  con- 
vergence. In  hyperphoria,  one  eye  may  have  a  tendency 
upward,  or  the  other  eye  downward,  and  these  relations 
may  be  interchangeable.  The  term,  therefore,  does  not 
indicate  where  the  fault  lies.  For  instance,  right  hyper- 
phoria means  that  the  superior  rectus  of  the  right  eye  is  too 
strong  for  the  inferior  rectus  of  the  same  eye,  or  that  the 
inferior  rectus  of  the  left  eye  is  too  strong  for  its  superior 
rectus.  Right  hyperphoria  means,  then,  that  the  right  eye 
has  a  tendency  to  turn  higher  than  the  left. 

Orthotropia  is  a  term  used  to  express  perfect  binocular 


84  A    MANUAL   OF    CLINICAL   OPHTHALMOLOGY. 

fixation  ;  lleterotropia,  a  turning  from  parallelism  ;  Esotropiin, 
a  turning  inward,  convergent  squint;  Exotropiat  a  turn- 
ing outward,  divergent  squint;  Hypertropia,  a  turning 
upward ;  Hyperesotropia,  a  turning  of  one  eye  upward  and 
inward,  and  Hyperexotropia,  a  turning  of  one  eye  upward 
and  outward. 

The  strength  of  an  ocular  muscle  is  measured  by  its  ability 
to  overcome  prisms,  while  both  eyes  are  fixed  on  a  small 
light  at  6  m.  The  external  recti,  abduction,  overcome  in 
the  average  8°,  and  the  internal  recti,  adduction,  30°. 
The  superior  rectus  of  one  and  the  inferior  rectus  of  the 
other  eye  (sursumduction)  overcome,  on  the  average,  3°. 
This  power  to  overcome  prisms  may  be  greatly  increased 
by  exercise. 

The  procedure  is  not  difficult.  Place  a  small  light  6  m. 
away  and  instruct  the  patient  to  look  steadily  at  the  flame 
with  both  eyes.  To  measure  the  strength  of  the  internal 
recti,  adduction,  place  a  prism  of  10°  with  the  angle  /;/ 
before  the  right  eye.  The  image  of  the  flame  is  thrown  to 
the  right  of  the  fovea,  and  double  images  are  momentarily 
seen  until  the  internal  rectus  contracts,  and  thus  rotates 
the  eye  inward  till  the  fovea  reaches  the  site  of  the  image 
and  there  is  fusion  of  the  images.  Another  prism  of  10° 
introduced  before  the  left  eye,  angle  in,  throws  the  image 
to  the  left  of  the  fovea;  the  internal  rectus  contracts  to  the 
same  extent,  and  again  single  images  are  seen.  This  pro- 
cedure is  carried  on  until  the  internal  recti  can  no  longer 
fuse  the  images.  The  highest  prism  through  which  single 
images  can  be  seen  is  the  measure  of  adduction.  While 
overcoming  prisms  of  increasing  strength,  the  eyes  are 
seen  to  become  more  and  more  turned  inward.  To 
measure  the  strength  of  the  external  recti,  abduction,  prisms 
of  increasing  strength  with  their  angles  outward,  are  placed 


FUNCTIONAL    MUSCULAR    AFFECTIONS.  85 

before  the  eyes,  until  about  7°  are  used.  In  order  to  over- 
come the  double  images  one  eye  is  deflected  strongly  ont- 
iunrd,  that  is  to  say,  the  external  rectus  of  that  eye  is 
contracted. 

The  angle  of  the  prism  is  placed  in  the  direction  of  the 
action  of  the  muscle  to  be  tested. 

In  low  degrees  of  heterophoria,  the  diagnosis  depends 
on  the  induction  of  artificial  diplopia,  and  on  establishing 
the  relation  to  each  other  of  the  two  images  thus  induced 
at  infinity,  and  at  the  reading  distance.  In  testing  for  hy- 
perphoria,  lateral  diplopia  must  be  produced  by  a  prism 
strong  enough  to  overcome  either  the  external  or  internal 
rectus.  As  the  external  recti  at  6  m.  are  the  weaker  mus- 
cles, a  prism  of  4°,  held  horizontally  a  few  inches  in  front 
of  each  eye,  with  its  angle  outward,  may  be  used.  In 
orthophoria,  the  images  of  the  candle  flame  at  6  m.  will 
be  side  by  side  in  the  horizontal  plane.  In  hyperphoria 
the  images  will  be  lateral,  but  one  higher  than  the  other. 
For  example,  in  left  hyperphoria,  the  left  eye  is  released 
by  the  prism  of  8°,  which  the  external  recti  cannot  over- 
come, from  the  necessity  of  maintaining  binocular  vision, 
and,  yielding  to  its  abnormal  disposition  to  deflect  from 
parallelism,  turns  upward.  Hence  its  image  will  be  lower 
than  the  image  of  the  right  eye.  The  prism  required 
to  restore  it  to  the  plane  of  the  image  of  the  right  eye,  with 
its  angle  upward,  will  be  the  angular  measurement  of  its 
displacement,  and  the  left  hyperphoria  will  equal  that  num- 
ber in  prismatic  degrees. 

In  testing  equilibrium  of  the  lateral  muscles  a  prism, 
strong  enough  to  overcome  the  action  of  the  superior  or 
inferior  rectus,  will  give  vertical  diplopia.  If  the  lateral 
muscles  are  in  equilibrium,  the  images  will  be  in  a  vertical 
plane.  In  esophoria,  the  candle  flame  at  6  m.,  seen  by  the 


86  A    MANUAL   OF   CLINICAL   OPHTHALMOLOGY. 

right  eye,  will  be  to  the  right  of  the  vertical  plane  passing 
through  the  image  seen  by  the  left  eye,  homonymous 
diplopia ;  and  in  exophoria  the  image  seen  by  the  right 
eye  will  be  to  the  left,  crossed  diplopia,  and  the  prism,  base 
out  in  esophoria  and  base  in  in  exophoria,  which  restores 
the  image  seen  by  the  right,  into  the  vertical  plane  of  the 
left,  will  be  the  angular  measurement  of  the  deviation. 

For  the  reading  distance,  35  cm.,  the  tests  are  conducted 
in  precisely  the  same  way,  but  the  object  for  fixation  should 
be  the  size  of  letters  ordinarily  read  at  that  distance. 

Esophoria  is  usually  greatest  in  the  distance,  and  exo- 
phoria at  the  near  point.*  Hyperphoria  is  the  same  at  all 
distances.  In  many  cases  of  heterophoria  it  cannot  be  de- 
termined which  eye  is  at  fault.  We  are  sometimes  aided  in 
diagnosis  by  information  supplied  by  the  patient  as  to  which 
image,  during  artificial  diplopia,  wanders  from  equilibrium, 
which  seems  to  the  patient  to  be  the  true  and  which  the 
false,  and  by  the  condition  of  the  refraction.  If  a  refraction 
error  exists,  and  is  greater  in  one  eye  than  in  the  other,  or 
if  the  acuity  of  vision  differs  in  the  two  eyes,  the  affected 
muscle  may  be  ascribed  to  the  weaker  eye. 

As  has  just  been  intimated,  heterophoria  is  influenced 
by  refraction.  Hypermetropia  and  hypermetropic  astig- 
matism cause  esophoria  in  a  very  considerable  proportion 
of  cases,  and  are  found  associated  with  it.  Although  exo- 
phoria cannot  be  said  to  depend  on  refraction  error,  it  is 
frequently  associated  with  myopia  and  myopic  astigmatism. 
Hyperphoria  seems  to  be  largely  independent  of  ametropia. 

The  local  symptoms  are  those  of  accommodative  strain, 
and  are  of  little  value  in  the  diagnosis.  The  reflex  symp- 
toms are  at  times  severe — headache,  nausea  and  vomiting, 


*  In  testing  muscles,  ametropic  and  presbyopic  corrections  should  be  worn. 


FUNCTIONAL    MUSCULAR    AFFECTIONS.  8/ 

indigestion,  choreic  movements,  and  the  various  vague 
and  misleading  phenomena  of  nervous  prostration.  On 
the  other  hand,  they  may  be  slight  or  altogether  wanting. 

The  diagnosis  of  heterophoria  is  not  difficult,  although 
its  detection  may  require  patient  and  skillful  manipula- 
tion. Double  vision  may  never  have  been  noticed  by 
the  patient,  but  can  be  often  produced  by  covering  one 
eye  with  a  red  glass  while  the  patient  looks  at  a  small 
flame  at  6  m.  With  a  little  perseverance,  the  patient  will 
acknowledge  seeing  the  two  lights,  one  natural  in  color 
the  other  red,  and  by  the  relations  they  bear  to  one  another, 
the  kind  and  degree  of  heterophoria  may  be  determined. 
And  this  is  true  whether  the  squint  is  high -or  low.  Even 
in  cases  of  long-continued  internal  or  external  strabismus, 
where  the  patient  has  ceased  to  have  double  images  by 
the  unconscious  suppression  of  one,  its  existence  may  be 
thus  recognized ;  and  when  the  patient  is  convinced  that 
he  really  sees  two  lights,  the  diagnosis  is  simple.  In  treat- 
ment it  is  important  that  the  patient  shall  acknowledge  the 
two  lights,  for  the  surgeon  is  guided  during  his  operation 
by  the  new  position  of  the  images. 

Maddox  has  suggested  the  use  of  a  glass  rod,  instead  of 
prisms,  in  the  determination  of  heterophoria.  A  glass 
rod  is  a  strong  cylinder  which  distorts  the  natural 
flame  into  a  long  streak  of  light.  The  difference  between 
the  image  seen  by  the  eye  before  which  the  glass  rod  .is 
placed  and  that  seen  by  the  other  eye,  is  so  marked  that 
binocular  fixation  is  not  possible  in  the  absence  of  muscular 
equilibrium.  If,  for  instance,  the  rod  is  placed  before  the 
right  eye  in  an  exactly  vertical  position,  the  streak  of  light 
will  be  horizontal,  and  in  orthophoria  the  light  will  be  seen 
directly  in  the  centre  of  the  streak.  In  hyperphoria  the 
light  will  be  above  or  below  the  streak.  In  esophoria  it 
will  be  to  the  left,  and  in  exophoria  to  the  right  of  the 


88  A    MANUAL   OF   CLINICAL   OPHTHALMOLOGY. 

streak.  The  light  will  be  restored  to  its  proper  position  in 
heterophoria  by  a  prism  of  necessary  degree  with  its  angle 
in  the  direction  indicated  by  the  existing  conditions ;  or  in 
testing  for  esophoria  or  exophoria,  the  rod  may  be  held 
horizontally,  and  the  streak  of  light  thus  rendered  vertical. 
It  will  then  be  necessary  for  the  patient  to  determine  whether 
the  streak  is  to  the  right  or  left  of  the  light.* 

Treatment. — In  every  instance,  the  refraction  should  be 
examined,  and  ametropia  corrected.  This  procedure  alone 
will  in  some  cases,  and  particularly  in  esophoria,  be  found 
sufficient  to  modify  the  defect  or  even  restore  the  muscles 
to  a  condition  of  equilibrium.  No  arbitrary  rules  can  be 
laid  down  for  the  treatment  of  the  muscular  anomaly  itself. 
It  is  a  functional  affection,  subject  to  variations  in  the 
degree  of  the  defect,  as  well  as  in  the  severity  of  its  symp- 
toms. In  general,  experience  teaches  that  (i)  prisms 
should  be  tried ;  (2)  that  the  degree  to  be  worn  shall 
approach  as  nearly  as  practicable  the  total  degree  of  insuf- 
ficiency ;  (3)  that  they  should  be  constantly  worn,  excepting 
in  exophoria  for  near,  where  there  is  orthophoria  for  dis- 
tance ;  (4)  that  prisms  should  be  worn  long  enough  to 
allow  the  muscles  time  to  spontaneously  regain  their  equi- 
librium ;  (5)  that  prisms  may  develop  latent  heterophoria. 
If  the  correction  of  the  ametropia  and  the  wearing  of 
prisms  prove  ineffectual,  tenotomy  must  be  performed. 


HETEROTROPIA. 

STRABISMUS  or  SQUINT. — Heterotropia  is  a  deviation  of  the 
visual  axis  of  one  eye  from  that  of  the  other  in  the  act  of 
vision,  the  result  of  muscular  overaction,  or  of  muscular 


*  It  is  essential  in  the  diagnosis  of  muscular  anomalies,  that  the  patient's 
head  shall  be  held  erect,  inclining  to  neither  side. 


HETEROTROPIA.  89 

weakness.  Ordinarily,  the  squint  is  of  such  degree  that 
simple  inspection  is  sufficient  to  designate  the  eye  affected. 
When  the  patient  fixes  an  object  indifferently  with  either 
eye,  the  squint  is  alternating.  If  the  same  eye  always 
deviates,  the  strabismus  is  mono-lateral,  or  constant.  To 
determine  the  character  of  the  deviation  more  accurately, 
the  patient  is  directed  to  look  at  a  small  flame  at  6  m. 
with  each  eye  alternately,  the  other  being  covered  with  a 
card,  and  if  no  deviation  of  the  eye  behind  the  card  is 
present  there  is  binocular  vision  for  that  distance.  The 
light  is  now  brought  within  50  cm.  of  the  eye  and  the 
preceding  test  repeated.  If  again  there  is  no  deviation, 
the  squint  is  only  apparent,  and  due  to  a  large  angle  a  in 
hypermetropia,  or  to  a  small  angle  a  in  myopia.  If  one 
eye  suddenly  deviates,  the  condition  is  termed  concom- 
itant strabismus.  If  the  sound  eye  turns  from  fixation, 
when  covered,  the  movement  is  termed  secondary  deviation. 
In  differentiating  paralysis  of  an  ocular  muscle  from  func- 
tional squint,  the  action  of  the  muscle  in  the  former  is  inter- 
mittent and  limited,  and  the  secondary  is  always  greater  than 
the  primary  squint.  The  image  of  the  squinting  eye  is  after 
a  time  unconsciously  suppressed,  and  the  most  scientific 
method  of  determining  the  character  and  degree  of  the  de- 
viation, is  to  compel  recognition  of  the  double  images  which 
are  invariably  present.  To  accomplish  this  end,  repeated 
examinations  with  colored  glasses  adjusted  before  the  eyes, 
and  the  exercise  of  a  considerable  amount  of  patient  manipu- 
lation, are  necessary.  A  deep-blue  or  red  glass,  held  before 
the  fixing  eye,  so  subdues  its  image  that  the  patient  will 
more  readily  recognize  the  false  and  brighter  image  seen  by 
the  deflected  eye.  It  is  not  infrequently  found  by  this 
method  that  ihefa/seis  not  on  a  horizontal  plane  with  the  true 
image,  but  lies  above  or  below  the  plane  in  this  meridian, 


90  A    MANUAL   OF    CLINICAL   OPHTHALMOLOGY. 

demonstrating  the  involvement  of  other  as  well  as  the  lateral 
muscles. 

INTERNAL  STRABISMUS,  ESOTROPIA,  is  the  deviation  in- 
ward of  one  eye,  and  is  in  four-fifths  of  all  cases,  caused 
by,  and  associated  with,  hypermetropia.  It  will  be  remem- 
bered, in  explanation  of  this  statement,  that  the  hyper- 
metrope  attains  visual  acuity  only  by  the  exercise  of  an 
abnormal  amount  of  accommodation,  involving  a  corres- 
ponding stimulation  of  the  internal  recti  muscles  (conver- 
gence). If  convergence  equal  accommodation,  the  visual 
axes  would  cross  in  close  proximity  to  the  eyes,  and  all 
objects  beyond  this  point  of  crossing  would  appear  double. 
In  order  to  maintain  single  and  moderately  clear  vision, 
the  patient  learns  to  unconsciously  throw  all  stimulation  into 
the  internal  rectus  muscle  belonging  to  the  eye  which,  by 
reason  of  its  higher  optical  defect,  or  impaired  vision  from 
other  causes,  is  more  or  less  strongly  converged.  Images 
are  on  the  same  side  (homonymous  diplopia). 

Strabismus  due  to  hypermetropia  is  likely  to  manifest 
itself  at  an  age  when  small  objects,  letters  of  the  alphabet, 
etc.,  are  first  noticed.  Moderate  degrees  of  hypermetropia, 
two  to  four  diopters,  may  be  overcome,  and  good  acuity  of 
vision  obtained,  by  accommodation  at  the  expense  of  conver- 
gence, but  in  higher  degrees,  the  accommodation  is  not 
strong  enough  to  overcome  the  error  of  refraction  for  any 
length  of  time  and,  in  consequence,  the  internal  recti  mus- 
cles do  not  receive  abnormal  impulse.  Hence  internal 
squint  is  rare  in  high  hypermetropia.  Amblyopia  of  the 
squinting  eye  is  common,  but  whether  the  imperfect  vision 
is  due  to  the  squint,  or  the  squint  to  the  imperfect  vision, 
is  a  question  yet  undecided. 

In  all  cases,  the  error  of  refraction  (hypermetropia)  should 
be  corrected,  and  in  a  certain  proportion,  where  the  strabis- 


HETEROTROPIA.  9! 

mus  is  of  moderate  degree  and  not  of  long  standing,  the 
eyes  may  be  brought  into  equilibrium  by  lenses  which 
remove  the  strain  on  the  accommodation ;  when,  however, 
binocular  vision  is  not  obtained  by  this  means,  the  internal 
recti  should  be  divided.  The  performance  of  this  operation 
is  followed  by  relief  of  the  deformity,  but  does  not  mate- 
rially improve  the  vision  of  the  squinting  eye. 

EXTERNAL  STRABISMUS,  EXOTROPIA,  is  an  outward  devi- 
ation of  the  visual  axis  of  one  eye  from  fixation,  frequently 
dependent  on  and  associated  with  myopia.  It  is  caused, 
not  by  over-action  of  the  external  recti  muscles,  but  from  a 
weakness  of  convergence,  consequent  upon  the  abolition  of 
the  necessity  for  accommodation,  due  to  the  increased  con- 
vexity of  the  ball  in  myopia.  It  is  occasionally  found  in 
eyes  not  myopic,  and  is  then  due  to  insufficient  action  of  the 
internal  recti  muscles,  or  to  acquired  monocular  blindness. 
The  images  in  divergent  strabismus  are  crossed  (heterony- 
mous  diplopia). 

Before  the  eye  becomes  permanently  deflected,  correction 
of  the  myopia  which  necessitates  the  use  of  a  normal 
amount  of  accommodation  for  near  objects,  and  hence  for 
convergence,  will  be  sufficient  to  effect  a  cure,  aided  by 
the  exercise  of  the  internal  recti  in  overcoming  prisms 
with  their  bases  out,  the  patient  gazing  at  a  bright  object 
6  m.  removed.  Tenotomy  of  the  external  recti  alone, 
or  in  conjunction  with  advancement  of  the  tendons  of  one 
or  both  internal  recti  muscles  will,  in  most  cases,  be  neces- 
sary. 

Functional  squint  upward,  or  downward,  is  seldom  mani- 
fested otherwise  than  as  complications  of  internal  and 
external  strabismus. 


PART  V. 
DISEASES  OF  THE  CONJUNCTIVA. 

CONJUNCTIVITIS. 

The  terminal  branches  of  the  transverse  facial,  facial, 
middle  temporal,  lacrymal,  infraorbital,  supraorbital,  pal- 
pebral,  frontal,  nasal  and  muscular  arteries,  ramify  loosely 
over  the  sclera  through  the  subconjunctival  mucous  mem- 
brane, and  are  injected  in  the  different  forms  of  conjunc- 
tivitis. They  are  not  normally  visible,  but  when  the  tissues 
supplied  by  them  are  irritated  or  inflamed,  they  are  visibly 
congested,  tortuous  and  movable,  their  calibre  gradually 
diminishing  as  they  approach  the  corneal  border.  In  the 
palpebral  conjunctiva,  the  individual  vessels  are  not  always 
seen,  but  a  diffuse  and  deep-seated  redness  is  imparted  to 
the  entire  surface  during  the  continuance  of  an  inflamma- 
tory process.  In  all  forms  of  conjunctival  inflammation, 
the  discharge,  an  invariable  symptom,  is  contagious. 

HVPERJEMIA. — Hyperaemia  of  the  conjunctiva  maybe 
acute  or  chronic.  In  either  case,  it  is  characterized  by  in- 
jection of  the  ocular  and  palpebral  vessels,  and  by  a  local- 
ized or  diffused  swelling,  chemosis,  cedema,  or  hyper- 
trophy of  the  mucous  follicles  or  papillae.  The  cause  of 
the  hyperaemia  will  usually  be  found  to  be  due  to  the  lodg- 
ment in  the  conjunctiva  of  a  small  foreign  body,  to  lacry- 
mal obstruction,  ametropia,  or  to  inverted  ciline.  The  patient 
will  complain  of  dryness,  burning  and  itching  of  the  affected 
lids,  and  of  lacrymation.  These  symptoms  are  relieved, 

92 


CONJUNCTIVITIS.  93 

and  the  patient  cured  in  a  few  days,  by  bathing  the  affected 
eye  with  cold  water,  followed  by  mild  astringent  washes. 
A  solution  of  cocaine  hydrochlorate  (2  per  cent),  dropped 
into  the  conjunctival  sac  every  two  or  three  hours,  will  give 
temporary  and  welcome  relief. 

ACUTE  CATARRHAL  CONJUNCTIVITIS. — In  acute  catarrhal 
conjunctivitis,  the  redness  and  other  symptoms  noticed  in 
hyperaemia  are  more  aggravated  and  pronounced,  and,  in 

FIG.  40. 


CONJUNCTIVAL  AND  SUBCONJUNCTIVAL  INJECTION. 

i.   Pericorneal  zone.     2.  Conjunctival  injection.     3,  3.  Sclerotic  injection. 

addition  to  them,  there  is  a  discharge  of  mucus  or  muco- 
pus  from  the  inflamed  surface.  During  closure  of  the  lids  in 
sleep,  the  discharge  collects  and  dries  on  their  free  margins, 
gluing  them  together.  There  is  also  pain,  photophobia,  and 
inability  to  use  the  eyes  in  prolonged,  close  work.  It  is  a 
universally  common  affection,  occurs  idiopathically  and  in 
epidemic  form,  "  pink-eye,"  and  may  arise  from  the  causes 
which  induce  hyperaemia,  from  inflammation  of  contiguous 


94  A    MANUAL   OF    CLINICAL   OPHTHALMOLOGY. 

membranes,  or  from  contagion.  Treatment  consists  in 
removal  of  the  cause,  in  the  local  application  of  astringent 
lotions,  and  in  marginal  inunctions  to  prevent  gluing. 
The  patient  is  directed  to  bathe  the  eyes  frequently  through 
the  day  with  the  following  effective  lotion  : — 

R .     Sodii  biboratis, gr  xx 

Aquae  camphonv, 

Aquae  destillat aa 31], 

and  to  rub  Pagenstecher's  ointment, — 

K .     Hydr.  oxidi  flavi, gr  j 

Ungt.  petrolei, 3J, 

along  the  margin  of  the  lids  on  going  to  bed  at  night. 
Hydrochlorate  of  cocaine  (gr.  ij— 5j)  may  be  added  to  the 
lotion  if  there  are  special  indications  for  its  employment. 

CHRONIC  CATARRHAL  CONJUNCTIVITIS  is  due  to  the  long 
continuance  of  one  or  more  of  the  causes  noticed  in  the 
etiology  of  the  acute  form,  to  which  might  be  added  smoky 
or  dusty  atmosphere,  and  poor  hygienic  surroundings.  In 
the  chronic  form  of  the  disease  it  may  be  necessary,  in 
addition  to  the  treatment  already  given,  to  frequently 
apply  to  the  everted  conjunctiva  of  the  lids,  the  nitrate  of 
silver  in  solution  (grs.  ij-5j),  copper  sulphate  (gr.  j-5j),  or 
a  solution  of  tannic  acid  in  glycerine.*  A  severe  case 
is  usually  followed  by  blepharitis  marginalis  or  angularis, 
dermatitis  angularis,  eversion  of  lower  punctual  with  epi- 
phora, and  by  keratitis. 

The  use  of  caustics  is  contraindicated  in  anaemia  of  the 


*  H.     Tannic  Acid, 

Glycerine, 
M.     S. — Apply  to  everted  lids  every  other  day. 


CONJUNCTIVITIS.  95 

conjunctiva,  or  while  the  exudation  is  thin  and  sanious,  and 
indicated  in  high  degrees  of  conjunctival  injection  when 
the  discharge  is  excessive,  thick  and  purulent.  The  strength 
of  the  solution,  and  the  intervals  between  applications, 
depend  on  the  amount  and  purulency  of  the  discharge. 
Its  strength  should  be  lessened  as  the  inflammation  dimin- 
ishes. 

VERNAL  CATARRH  is  characterized  by  hypertrophy  of 
the  conjunctival  epithelium,  deposition  of  inflammatory 
exudation  at  the  corneo-scleral  margin,  vascular  fullness,  and 
by  peripheral  opacity  of  the  cornea.  The  ocular  conjunctiva 
is  but  slightly  injected,  while  the  palpebral  conjunctiva  is,  on 
the  other  hand,  thickened,  smooth,  and  pallid.  The  affection 
is  binocular,  affecting  children  and  young  adults,  appears 
in  the  spring  of  the  year,  attains  a  maximum  of  severity 
in  a  few  weeks,  and  continues,  practically  uninfluenced  by 
treatment,  with  slight  exacerbations  and  remissions,  until 
frost,  when  it  slowly  disappears.  Its  average  duration  is 
four  years.  The  symptoms  are  those  of  chronic  catarrhal 
conjunctivitis. 

FOLLICULAR  CONJUNCTIVITIS  is  characterized  by  the  de- 
velopment, immediately  under  the  palpebral  epithelium,  of 
small,  round  and  prominent,  pale-red  follicles,  consisting 
of  lymph  deposits,  arranged  in  parallel  rows.  These 
deposits  are  more  marked  and  numerous  near  the  fornix 
in  the  lower  lid.  When  the  inflammation  has  subsided, 
they  disappear,  leaving  no  cicatrix  in  the  conjunctiva. 
The  disease  is  acute  or  chronic.  In  the  former  case,  the 
inflammation  is  severe,  the  hypersemia  intense,  and  there 
is,  in  the  region  of  the  fornix,  a  marked  infiltration  of  the 
tissues,  with  pericorneal  injection.  The  secretion  is  thin 
and  abundant.  In  four  or  five  days  after  the  onslaught  of 
the  disease,  follicles  appear  in  both  lids.  In  the  chronic 


96  A    MANUAL   OF    CLINICAL   OPHTHALMOLOGY. 

form,  the  signs  of  inflammation  are  not  marked,  and  the 
follicles  are  limited  to  the  lower  lids. 

Follicular  conjunctivitis  is  induced  by  contagion,  pro- 
longed local  medication,  such  as  applications  of  nitrate  of 
silver,  instillation  of  atropine,  etc.,  and  by  unhygienic  sur- 
roundings. The  disease  may  last  for  weeks  or  months,  but 
the  prognosis  is  favorable.  The  cause  should  be  ascer- 
tained and  removed,  and  remedies  employed  to  subdue  the 

Fin.  41. 


GRANULAR  CONJUNCTIVITIS. 

inflammation  and  indirectly  remove  the  follicles.  Treatment 
is  not  primarily  directed  toward  the  eradication  of  the 
follicles. 

GRANULAR  CONJUNCTIVITIS,  OR  TRACHOMA,  consists  of 
deposition  in  the  stroma  of  the  conjunctiva  of  small  masses 
of  lymphoid  cells  (Fig.  41),  most  marked  in  the  upper  lid. 
These  cells  are  nourished  by  newly  formed  blood-vessels, 
and  gradually  undergo  transformation  into  connective  tis- 
sue elements.  The  process  is  a  true  hyperplasia,  always 


CONJUNCTIVITIS.  97 

attended  by  severe  inflammation,  and  eventuates  in  per- 
manent tissue  changes  in  the  conjunctiva  and  cartilage. 
The  granulations,  which  first  develop  in  the  upper  lid,  are 
numerous,  adjacent  to  one  another,  and,  spreading  over  the 
surface  until  the  entire  lid  is  involved,  present  the  charac- 
teristic appearance  of  minute  bunches  of  grapes,  of  a  deep 
red  color.  The  granulations  are  smaller  and  less  thickly 
spread  over  the  surface  of  the  lower  lid.  Through  an  exten- 
sion of  the  inflammatory  process,  the  ocular  conjunctiva 
and  cornea  are  eventually  involved. 

The  inflammation  is  of  a  high  grade  in  the  acute  form  of 
the  disease,  develops  rapidly,  and,  if  checked  before  merging 
into  the  chronic  form,  is  not  attended  by  permanent  con- 
sequences of  a  serious  character.  The  chronic  form, 
which  is  most  frequently  seen  in  hospital  practice,  is 
divided  into  three  stages. 

In  the  first  stage,  the  stage  of  development,  the  injection  of 
the  conjunctival  vessels  may  be  moderate  or  intense,  and 
there  is  either  a  gradual  or  rapid  infiltration  of  the  conjunc- 
tiva of  the  upper  lid.  In  the  former  case,  the  development 
of  granulations  is  slow ;  in  the  latter,  numerous  and  large 
granulations  quickly  appear  on  the  conjunctiva  of  the  upper 
lid,  accompanied  by  a  constant  and  profuse  discharge,  the 
acute  thus  passing  into  the  chronic  form.  In  the  second 
stage,  or  stage  of  acme,  the  conjunctiva  of  the  upper  lid  is 
transformed,  its  proper  epithelium  destroyed,  old  blood 
vessels  enlarged,  new  ones  formed,  and  granulation  cells 
deposited  in  its  stroma  Owing  to  these  changes,  the 
conjunctival  surface  is  irregularly  roughened  by  eleva- 
tions and  depressions.  The  conjunctiva  of  the  lower  lid 
undergoes  similar  alterations  in  a  less  degree.  The  ocular 
conjunctiva,  particularly  the  upper  section,  is  hyperaemic 
and  the  seat  of  granulations.  The  scleral  and  episcleral 
9 


98  A    MANUAL   OF   CLINICAL   OPHTHALMOLOGY. 

veins  are  distended.  Even  the  cornea  is  invaded,  usually  in 
its  upper  half.  It  becomes  vascular,  opaque,  and  denuded 
of  epithelium,  which  is  destroyed  either  by  extension 
of  the  peculiar  granular  inflammation  into  its  stroma  by 
continuity,  or  by  friction  of  the  roughened  upper  lid. 
The  keratitis  thus  produced  is  a  superficial  vascular  inflam- 
mation, pannus  (Fig.  42).  In  the  third  stage,  or  stage 
of  cicatrization,  the  granulations  have  disappeared  and  the 
conjunctival  surface  has  lost  its  roughness.  The  membrane 
is,  however,  shrunken  and  streaked  with  one  or  more  hori- 

Fir..  42. 


PANNUS  AFFECTING  UPPER  HALF  OK  CORNEA. 

zontal  white  lines,  marking  its  close  anatomical  connec- 
tion with  the  underlying  cartilage,  which  is  curved  with 
its  convexity  outward  (entropion).  The  lids  droop,  the 
cilia;  are  irregular  (distichiasis),  or  turned  inward  against  the 
cornea.  The  palpebral  space  is  narrowed  by  atrophy 
of  the  conjunctiva  in  its  entirety.  The  cornea  is  partly 
opaque,  and  is  traversed  by  a  few  tortuous  vessels.  The 
lower  lid  undergoes  changes  and  malformations  of  the  same 
character,  but  in  less  degee. 

The  symptoms  are,  in  the  first  stage,  pain,  burning,  and 


CONJUNCTIVITIS.  99 

itching  of  the  lids,  discharge  of  pus  or  muco-pus,  lacry- 
mation,  photophobia,  and  inability  to  use  the  eyes.  In  the 
second  stage,  dimness  of  vision  is  added  to  the  above 
symptoms,  and,  in  the  third  stage,  there  is  a  partial  loss 
of  vision  with  the  annoying  symptoms  caused  by  in- 
verted lashes,  etc. 

Permanent  deformity  of  the  lids,  partial  ptosis,  limited 
movement  of  the  ball,  opaque  cornea,  and  staphyloma  are 
the  frequent  and  distressing  sequelae  of  the  dreaded  disease. 

It  is  caused  by  unhygienic  habits  of  life,  contagion,  and 
scrofula. 

The  disease  occurs  most  frequently  among  young  persons 
between  the  ages  of  fifteen  and  thirty,  and  is  usually  binocu- 
lar. Germans,  Poles,  Hungarians,  Egyptians,  and  Italians 
are  peculiarly  susceptible  to  granular  conjunctivitis,  whether 
as  the  result  of  inherent  peculiarities  of  temperament,  or 
from  neglect  of  sanitary  laws,  has  not  been  definitely  deter- 
mined. 

The  prognosis  is  unfavorable.  Complete  recovery  is 
rare.  The  disease  lasts  for  years. 

Treatment. — The  affection  is  greatly  modified  by  treat- 
ment, which  is  largely  local.  For  the  first  stage,  antiphlo- 
gistics  and  antiseptic  remedies  are  indicated,  such  as  leech- 
ing, applications  of  bichloride  of  mercury,  1-500  or 
i-iooo,  scarification  of  the  everted  lids,  and  frequent  cold 
water  baths  to  the  eye.  After  the  granulations  have 
formed,  the  treatment  which  at  present  would  seem  to  prom- 
ise the  best  results,  is  extrusion  of  the  granules  by  expres- 
sion with  the  roller  forceps,  while  the  patient  is  under  the 
influence  of  anaesthesia.  The  older  treatment,  such  as 
cauterization,  the  application  to  the  granules  of  crystals  of 
copper,  or  alum,  or  of  the  mitigated  stick  of  the  nitrate  of 
silver  (thirty-three  per  cent.),  atropine,  and  inunctions  of 


IOO  A    MANUAL  OF   CLINICAL   OPHTHALMOLOGY. 

yellow  ointment  of  mercury  is,  at  best,  only  palliative.  It 
should  be  the  surgeon's  aim  to  abort  or  destroy  the  granula- 
tions. If  pannus  should  form  it  must  be  combated  by  an 
incision  of  the  blood-vessels  from  which  those  of  the  cornea 
are  derived  at  the  corneo-scleral  border,  and  by  instillation 
of  atropine  and  frequent  hot-water  baths  to  the  eye.  In  the 
third  stage,  or  stage  of  cicatrization,  diverted  lashes  should 
be  removed,  the  entropion  relieved  by  operation,  and  the 
contracted  commissure  widened,  if  any  of  these  conditions 
are  present  as  a  result  of  the  inflammation.  The  general 
system  should  be  supported  by  tonics,  pure  air,  good  food 
and  exercise.  Confinement  in  a  dark  room  should  be 
avoided. 

BLENNORRHOZAL,  PURULENT,  or  GONORRHOZAL  CONJUNC- 
TIVITIS, or  OPHTHALMIA  NEONATORUM,  is  an  intense  inflam- 
mation of  the  ocular  and  palpebral  conjunctiva  with 
chemosis,  hypertrophy  of  epithelium  and  papillae,  char- 
acterized by  an  excessive  discharge  of  pus  or  muco- 
pus.  It  is  acute  in  its  course  unless  a  sequel  of  acute 
catarrhal  conjunctivitis.  Within  a  few  hours  of  its  incep- 
tion, the  upper  lid  becomes  greatly  swollen,  smooth,  and 
shiny  on  its  cutaneous  surface.  The  lashes  are  grouped 
into  bundles  and  covered  with  discharges.  The  lower  lid 
is  puffed  out,  pus  and  tears  escape  from  the  outer  canthus, 
and  the  conjunctiva,  infiltrated  with  serum,  is  elevated  from 
the  sclera,  so  that  the  cornea  appears  sunken.  In  a  few 
days  a  section  of  the  cornea  loses  its  transparency,  the 
epithelium  is  cast  off,  forming  an  ulcer,  which,  in  the  graver 
cases,  advances  to  perforation  with  escape  of  aqueous,  and, 
finally,  to  sphacelus  of  the  entire  cornea ;  or  the  inflamma- 
tion moderates,  swelling  subsides,  discharge  lessens,  and  the 
products  of  inflammation  are  gradually  absorbed  without 
involvement  of  the  cornea,  or,  if  involved,  it  recovers  with 


CONJUNCTIVITIS.  IOI 

opacity  and,  probably,  anterior  synechia.  The  prolonged 
inflammation,  rather  than  its  intensity,  decides  the  question 
of  corneal  infection.  The  keratitis  is  induced  by  interruption 
of  the  blood  supply,  the  result  of  pressure  on  the  pericorneal 
and  episcleral  vessels  from  exudation  in  that  region.  The 
serum  may  become  partially  absorbed,  but  the  conjunctiva 
is  still  elevated  and  uneven  from  the  presence  of  more  or 
less  exudation.  During  and  for  several  weeks  after  the 
termination  of  the  acute  stage,  the  conjunctiva  of  both  lids, 
the  upper  lid  more  especially,  projects  in  horizontal  ridges 
with  deep  furrows  between  them  resembling  granular  con- 
junctivitis, caused  by  the  excess  of  inflammatory  exudation, 
which  persists  long  after  the  other  symptoms  of  inflamma- 
tion have  subsided. 

The  cause  is  infection.  Ophthalmia  neonatorum  is  caused 
by  the  absorption  by  the  conjunctiva  of  other  as  well  as 
gonorrhceal  pus.  The  mother  giving  birth  to  an  infant 
which  becomes,  in  a  day  or  two,  affected  with  this  disease,  is 
not  necessarily  a  subject  of  gonorrhoea.  In  other  words, 
the  vaginal  secretion  causing  the  disease,  is  not  always 
gonorrhceal  in  character.  The  inflammation  primarily 
attacks  one  eye,  and  is  conveyed  by  the  inter-communicat- 
ing nasal  ducts,  or  by  carelessness,  to  the  other,  or  both 
eyes  are  affected  simultaneously  and  from  a  single  cause. 

Treatment  in  the  acute  stage  consists  in  applications  of 
ice,  or  ice  water,  renewed  every  few  minutes  day  and  night, 
thorough  cleansing  of  the  conjunctival  sac  with  saturated 
solution  of  boric  acid,  which  should  be  squirted  into  the 
commissure  every  half  hour  by  means  of  an  eye-dropper,  or 
absorbent  cotton  may  be  used  for  the  purpose.  Nitrate  of 
silver  (grs.  v  to  Sj  °r  grs-  x  to  5j,  if  the  discharge  of  pus 
is  abundant)  should  be  applied  to  the  everted  lids  once 
or  twice  daily.  These  remedies,  with  atropine  (gr.  iv-5j), 


IO2  A    MANUAL    OF    CLINICAL   OPHTHALMOLOGY. 

when  the  cornea  is  threatened  or  attacked,  are  the  most 
effective.  In  the  subacute  stage,  nitrate  of  silver  in  dimin- 
ishing strength,  and  at  increasing  intervals,  until  the  palpe- 
bral  regions  are  of  normal  smoothness,  mild  antiseptic 
washes,  and  vaseline  applied  to  the  lids  at  night  to  prevent 
the  gluing  together  of  their  free  margins,  are  indicated. 

PHLYCTENULAR,  LYMPHATIC,  SCROPHULOSIS  OR  HKKI-KTIC 
CONJUNCTIVITIS  is  a  frequent  affection  among  children.  It  is 
characterized  by  the  formation  in  the  conjunctiva  of  one  or 
more  blebs  containing  serum  or  pus.  The  vessels  supply- 

FIG.  43. 


PHLYCTENULAR  OPHTHALMIA,  CONJUNCTIVAL  FORM. 

ing  the  affected  region,  are  injected  and  pursue  a  tortuous 
course  from  the  fornix  to  their  endings  at  the  phlyctenulc. 
Other  parts  of  the  conjunctiva  are  but  slightly,  if  at  all, 
injected.  The  symptoms  are  not  severe,  except  in  the  pur- 
ulent form,  and  cause  the  patient  little  inconvenience.  At- 
tention to  the  diet,  pure  air,  out-door  exercise,  the  removal 
of  the  cause  of  reflex  irritation,  such  as  worms  in  the  intes- 
tinal canal,  and  difficult  dentition,  the  daily  application  to  the 
margin  of  the  lids  of  Pagenstecher's  ointment,  and  thorough 
cleansing  of  the  parts  with  a  saturated  solution  of  boric  acid 
will,  usually,  cure  the  inflammation  in  a  few  days.  Relapses 


CONJUNCTIVITIS.  IO3 

are  likely  to  occur,  involving  the  same  or  the  other  eye, 
or  the  two  eyes  simultaneously. 

CROUPOUS  CONJUNCTIVITIS  is  an  acute,  highly  contagious 
inflammation  of  the  conjunctiva,  characterized  by  the  for- 
mation on  a  part  or  on  the  whole  of  the  conjunctiva  of  a  thin, 
yellowish-white  membrane,  composed  of  albuminoid  and 
cellular  substances,  which  is  detached  without  difficulty, 
leaving  a  bleeding  point  or  surface.  The  disease  has  a  ten- 
dency to  recur.  It  is  an  infrequent  affection,  confined  prin- 
cipally to  children,  and  while  the  symptoms — swelling  of  the 
lids,  chemosis,  thin  and  abundant  discharge,  pain  and  heat 
— are  severe,  the  cornea  is  rarely  involved.  During  the  for- 
mation of  the  croupous  membranes,  caustics  must  be  avoided, 
and,  instead  of  their  use,  ice  compresses,  antiseptic  lotions, 
and  powdered  quinine,  dusted  over  the  diseased  surface, 
employed.  After  the  acute  stage,  a  blenorrhoeal  conjunc- 
tivitis persists,  and  this  is  successfully  combated  by  the 
application  of  the  nitrate  of  silver  (gr.  v— §j). 

DIPHTHERITIC  CONJUNCTIVITIS  is  an  acute,  intense,  con- 
tagious inflammation,  characterized  by  the  deposition  in 
the  subconjunctival  tissue  of  a  yellowish-white  membrane, 
so  closely  interwoven  with  the  conjunctiva  that  its  detach- 
ment is  difficult.  The  local  symptoms — swollen  lids,  exten- 
sive chemosis,  acute  pain,  heat,  and  sanious  discharge — are 
severe  and  very  marked  in  character.  There  is  superadded 
to  them,  in  some  cases,  the  constitutional  symptoms  of 
diphtheria.  The  cornea  is  often  destroyed  through  ulcer- 
ation.  In  the  course  of  a  week,  the  false  membrane  and 
surrounding  conjunctiva  become  necrosed  and  slough  off, 
leaving  a  deep  ulcer,  which  heals  slowly.  A  more  or  less 
extensive  cicatrix  remains  to  permanently  alter  the  con- 
tour of  the  lid.  When  the  characteristic  diphtheritic  pro- 


IO4  A    MANUAL   OF   CLINICAL   OPHTHALMOLOGY. 

cess  has  subsided,  a  purulent  or  semi-purulent  conjunc- 
tivitis remains.  The  disease  attacks  one  or  both  eyes,  is 
sporadic  or  epidemic,  may  precede  or  follow  similar  mem- 
branes in  the  throat  or  nose,  or  run  its  course  as  a  purely 
local  affection. 

The  prognosis  is  not  favorable.  The  treatment,  during 
the  formation  and  continuance  of  the  membrane,  is  antiphlo- 
gistic and  antiseptic.  Atropine  locally,  and  constitutional 
remedies,  suited  to  the  age  and  necessities  of  the  patient, 
should  be  employed.  Salivation  is  recommended  in  adult 
patients. 

XEROSIS  is  a  dryness  of  the  conjunctiva  due  to  destruc- 
tion of  the  papillae  and  follicles  through  atrophy  of  the 
mucous  membrane  from  severe  and  long-continued  inflam- 
mation (diphtheritic  or  granular  conjunctivitis),  or  to  the 
improper  and  continued  use  of  caustics.  The  functions  of 
the  eye  are  interfered  with,  and  may  be  destroyed,  through 
resulting  opacities  of  the  cornea.  Treatment  is  of  little 
avail.  Constant  instillations  of  glycerine  is  said  to  be 
palliative. 

PTERYGIUM  is  a  vascular  membrane,  triangular  in  shape, 
closely  resembling  in  appearance  and  structure  the  con- 
junctiva, on  which  it  is  superimposed.  Its  base  corresponds 
with  the  curve  of  the  sulcus  at  the  inner  canthus,  and  the 
growth  extends  horizontally  until  the  apex  has  invaded 
the  subepithelial  layer  of  the  cornea.  Its  apex  may  thus 
cover  in  part,  or  completely,  the  pupil.  It  may  appear  in 
both  eyes  simultaneously  or  be  confined  to  one.  In  rare 
instances  it  is  developed  from  the  outer  canthus.  It  is  an 
affection  of  slow  growth,  and  is  most  frequently  found  in 
elderly  persons  who  have  been  exposed  to  wind  and  rain 
through  many  years  of  active,  outdoor  life.  Sailors  are 


CONJUNCTIVITIS. 


105 


peculiarly  liable  to  the  affection.  It  should  be  regarded  as 
an  hypertrophy  of  the  conjunctiva,  the  result  of  constant 
exposure  to  the  elements,  rather  than  as  an  inflammation. 

FIG.  44. 


PTERYGIUM. 

TUMORS. — Pinguecula  is  a  small,  yellowish-white,  fatty- 
like  growth,  usually  noticed  between  the  cornea  and  inner 
canthus.  It  is  harmless.  Granuloma,  or  Polypi  are  not 
infrequently  found  attached  to  the  conjunctival  surface 
after  an  injury  or  operation;  they  should  be  excised. 
Dermoid  cysts,  lipoma,  sarcoma,  and  melano-sarcoma  are 
also  found  in  the  conjunctiva.  They  should  be  removed 
and  the  wound  cauterized. 


PART  VI. 

DISEASES    OF    THE    LIDS    AND    LACRYMAL 
APPARATUS. 

CONGENITAL  MALFORMATIONS. 

COLOBOMA  is  a  fissure  of  one  or  both  lids,  and  is  often 
associated  with  similar  deformities  of  the  iris,  choroid,  and 
palate. 

EPICANTHUS  (Fig.  45)  is  a  widening  at  the  base  of  the 

FIG.  45. 


ElMCANTHUS. 


nose,  caused  by  a  redundancy  of  the  skin  in  this  situation. 
The  internal  angle  of  each  palpebral  fissure  is  partly 
covered,  and  the  fissures  apparently  shortened.  When  a 
fold  of  skin  at  the  centre  of  the  interpupillary  space  is 
elevated  by  forceps,  the  deformity  temporarily  disappears. 

PTOSIS  (Fig.  46),  is  a  drooping,  partial  or  complete,  of  the 
upper  lid,  from  paralysis  of  the  levator  palpebrae  branch  of 

106 


TRAUMATISM.  lO/ 

the  third  nerve.  This  condition  is  most  apparent  when  the 
patient's  gaze  is  directed  upward.  The  deformity  may  be 
relieved  by  operation. 


TRAUMATISM. 

Incised  and  punctured  WOUNDS,  involving  only  the  lids, 
and  not  penetrating  to  the  eye-ball,  should  be  sutured  and 
treated  antiseptically  with  the  double  purpose  of  preventing 
deformity  and  promoting  resolution. 

FIG.  46. 


PTOSIS. 

BURNS  from  acids,  alkalies,  molten  lead,  scalding  water, 
etc.,  may  lead  to  disastrous  results  from  the  formation  of 
cicatricial  contractions,  which  terminate  in  distortion  of  the 
lids,  adhesions  between  their  free  margins,  and  consequent 
narrowing  of  the  palpebral  fissure,  and  lead,  not  infrequently, 
to  destruction  of  the  conjunctival  sac.  The  aim  of  the  treat- 
ment is  to  prevent  marginal  and  surface  adhesions,  and  the 
formation  of  cicatricial  and  distorting  bands,  by  traction  and 
the  constant  application  of  oil  dressings  to  the  wounded 


IO8  A    MANUAL   OF    CLINICAL   OPHTHALMOLOGY. 

surfaces.  When  the  wound  is  superficial,  involving  a  lar^e 
portion  of  the  lid,  skin  grafting  should  be  employed,  and 
when  the  lid  is  destroyed,  a  plastic  operation  becomes 
necessary,  the  deficient  or  lost  tissue  being  supplied  from 
the  adjoining  parts. 

CONTUSION,  "black  eye,"  is  usually  the  result  of  violence, 
such  as  a  blow.  The  loose  connective  tissue  of  the  lids 
becomes  swollen,  ecchymosed,  and  presents  a  bluish  dis- 
coloration, which  is  a  source  of  annoyance  rather  than  of 
danger.  The  condition  may  be  speedily  relieved  by  the 
alternate  application  of  hot  and  cold  water,  to  which  is 
added,  in  the  proportion  of  one  to  eight,  the  tincture  of 
arnica,  or  a  wash  of  the  chloride  of  ammonium,  gr.  v-5J, 
may  be  substituted. 

INFLAMMATIONS. 

PHLEGMON,  ABSCESS,  is  an  acute,  purulent,  circumscribed 
inflammation  of  the  cellular  tissue,  attended  with  redness, 
swelling,  pain,  and  localized  elevation  of  the  temperature. 
The  abscess  is  at  first  hard,  gradually  increases  in  size, 
softens,  and  has  a  tendency  to  point  through  the  skin.  It 
may  be  the  result  of  injury,  of  cold,  or  develop  without 
assignable  cause.  When  situated  near  the  inner  angle,  the 
abscess  should  not  be  confounded  with  acute  inflammation 
of  the  lacrymal  sac. 

A  threatened  abscess,  may  be  aborted  by  the  local  appli- 
cation of  cold,  and  by  the  internal  administration  of  calcium 
chloride,  of  which  a  two-grain  pill  should  be  given  every 
two  hours  until  four  pills  are  taken.  When  the  inflamed 
area  presents  a  central  induration,  poultices,  followed  by  an 
early  incision,  parallel  with  the  margins  of  the  lid,  are 
indicated.  After  incision,  the  parts  should  be  frequently 
cleansed  with  antiseptic  lotions,  and  supported  by  a  com- 
press. 


INFLAMMATIONS.  IOO, 

HORDEOLUM,  STYE,  is  a  localized  inflammation  in  or 
near  the  bulb  of  an  eyelash.  It  rapidly  advances  to  pustu- 
lation,  and  is  accompanied  by  redness,  pain  and  swelling, 
particularly  when  situated  at  the  outer  angle,  and  by  local, 
and  sometimes  general,  increase  of  temperature.  There  is 
usually  a  succession  of  styes,  one  following  another  at 
irregular  intervals  for  several  weeks  or  months.  The  cause 
is  to  be  found  in  some  refraction  error,  or  in  an  impover- 
ished condition  of  the  system.  Treatment :  cold  com- 
presses in  the  early  stage  to  abort,  and  hot  poultices, 
later,  to  hasten  suppuration.  A  small  incision  may  be 
made  through  its  apex,  or  the  tumor  left  to  open  spon- 
taneously. 

BLEPHARITIS  is  an  inflammation  of  the  lids,  acute  or 
chronic,  dependent  upon  disease  of  contiguous  parts,  such 
as  the  various  forms  of  conjunctivitis,  orbital  disease,  ery- 
sipelas, etc. 

MARGINAL  BLEPHARITIS  is  a  chronic  inflammation  of  the 
free  margin  of  the  lids.  In  its  early  stage,  it  is  character- 
ized by  an  induration  around,  and  hypersecretion  of,  the 
sebaceous  glands  with  the  formation  of  minute  pustules, 
which  rupture,  leaving  small  ulcers.  The  secretion,  drying, 
forms  crusts  which  become  matted  with  the  ciliae.  When 
the  crusts  are  removed,  the  edge  of  the  lid  presents  a  series 
of  excoriated  and  bleeding  points.  The  entire  margin  is 
finally  involved  in  the  inflammatory  process,  the  ciliae  fall 
out,  and  are  replaced  by  a  few  fine  and  misdirected  hairs, 
or  they  may  be  altogether  absent.  The  symptoms  are  red- 
ness, swelling,  itching,  and  a  sensation  of  heat,  aggravated 
by  the  use  of  eyes  in  near  work,  by  smoke  and  other 
atmospheric  impurities.  It  occurs  in  children  and  young 
adults,  as  a  result  of  reflex  irritation,  ametropia,  and  scrofula. 

Treatment. — The  cause    should  be  ascertained   and  re- 


I  IO  A    MANUAL   OF    CLINICAL   OPHTHALMOLOGY. 

moved ;  the  ametropia  corrected  by  the  proper  lens ;  the 
reflex  irritation  from  painful  dentition,  or  from  intestinal 
worms,  relieved  by  suitable  remedies,  and  in  scrofula,  tonics 
and  alteratives  administered  with  good  food,  fresh  air,  and 
healthy  surroundings.  The  crusts  should  be  dissolved  by 
mild  alkaline  washes,  sodii  bicarb.,  or  biborate,  gr.  v-.^j,  the 
ulcers  stimulated  by  touching  them  with  a  pledget  of 
cotton  soaked  in  silver  nitrate,  gr.  v-5j,  and,  once  or  twice 
daily,  an  ointment  of  the  yellow  or  red  oxide  of  mercury 
(gr.  j,  vaseline  5j)  applied,  or,  in  stubborn  cases,  aristol  in 
the  same  strength  can  be  substituted  for  the  mercury. 


AFFECTIONS  OF  THE  SKIN. 

ERYTHEMA,  ECZEMA,  and  ERYSIPELAS  appear  occasionally 
on  the  lids,  as  elsewhere  on  the  body,  as  a  local  manifestation 
of  the  general  affection.  They  are  to  be  treated  on  the  prin- 
ciples laid  down  for  these  diseases. 

CEDEMA  is  a  symptom  of  orbital  disease,  of  purulent 
conjunctivitis,  and  of  nephritis.  In  all  cases  of  oedema 
without  local  cause,  the  urine  should  be  examined  for 
albumin.  It  requires  no  special  treatment. 

EMPHYSEMA  is  an  escape  of  air  into  the  cellular  tissue 
adjoining  the  lids,  induced  by  violent  sneezing,  blowing  the 
nose,  and  by  asthma.  Compression  by  a  roller  bandage 
is  the  only  treatment  necessary. 

RODENT  ULCER  begins  at  the  margin  of  a  lid,  usually 
the  lower,  as  a  small  excrescence  which,  in  time,  falls  off, 
leaving  an  excoriated  surface.  This  slowly  increases  in 
size  until  it  has  destroyed,  after  the  lapse  of  many  months 
or  years,  the  lid  and  neighboring  tissues.  The  pain  is 
inconsiderable.  The  treatment  consists  in  the  early  and 
complete  excision  of  the  diseased  part. 


AFFECTIONS    OF   THE   SKIN. 


Ill 


EPITHELIOMA  presents  in  its  initial  stage  similar  appear- 
ances to  the  rodent  ulcer,  but  is  distinguished  by  the 
rapidity  of  its  growth,  lancinating  pain,  thin,  offensive, 
ichorous  discharge,  and  by  its  tendency  to  recur  after  exci- 
sion. It  occurs,  as  does  the  rodent  ulcer,  in  elderly  per- 
sons. Early  excision  is  the  treatment.  The  application 
of  glacial  acetic  acid,  repeated  tri-weekly  until  the  ulcer  is 


FIG.  47. 


B. 


MEIBOMIAN  CYST. 


LID  FORCEPS. 

A,  Screw.     B,  Shank. 


cicatrized,  has  been  advocated.  It,  together  with  other 
remedies  of  the  same  class  that  have  been  proposed  from 
time  to  time,  is  not  to  be  employed,  however,  when  the 
patient  is  willing  to  submit  to  an  operation. 

LUPUS  is  a  tuberculous  infiltration  of  the  lid,  and  occurs 
usually  as  an  extension  of  the  disease  from  neighboring 
structures.  All  treatment  heretofore  devised  has  been 
simply  palliative.  No  cure  has  yet  been  found  for  tubercle. 


112  A    MANUAL   OF    CLINICAL   OPHTHALMOLOGY. 

XANTHELASMA  is  a  fatty  degeneration  of  the  skin,  of 
a  bright  yellow  color,  occurring  in  symmetrical  patches  on 
the  lids  of  both  eyes  near  their  inner  angle.  They  should 
be  excised  and  the  healthy  skin  drawn  together  by  sutures. 

CHANCRE  is  a  specific,  indurated  sore  of  the  lid,  due  to 
direct  contagion,  having  the  same  features  and  followed  by 
the  same  constitutional  infection,  that  characterize  chancre 
in  other  situations  of  the  body.  The  treatment  is  anti- 
syphilitic  and  constitutional. 

CHALAZION  (Fig.  47,  A)  is  a  small  cyst  developed  in  the 
tarsal  cartilage  from  obstruction  of  a  meibomian  duct, 
damming  its  secretion.  It  is  a  common  but  insignificant 
tumor,  easily  removed  by  excision. 

ECCHYMOSIS  is  an  effusion  of  blood  beneath  the  skin  or 
conjunctiva  from  traumatism,  or  from  idiopathic  rupture 
of  a  small  vein.  No  treatment  is  necessary. 

MILIUM  is  the  name  given  to  a  minute,  hard,  pearly-like 
growth,  situated  on  the  margin  of  the  lids,  or  in  the  skin. 
It  requires  no  treatment,  but  may  be  readily  removed  iTthe 
patient  so  desires. 


AFFECTIONS  OF  THE  EYELASHES 

TRICHIASIS  (Fig.  48)  is  that  condition  in  which  the  cili;u 
assume,  as  a  result  of  chronic  disease  of  the  conjunctiva, 
independent  directions,  some  normal  and  others  distorted. 
Those  turned  against  the  cornea  should  be  pulled  out,  or 
their  bulbs  excised. 

DiSTiCHiASis(Fig.  49)  is  the  condition  in  which  there  is  a 
second  irregularly  placed  row  of  lashes,  congenital  or  ac- 
quired, partially  or  wholly  in  contact  with  the  cornea.  This 
is  a  painful  complication  of  chronic  conjunctivitis.  Friction 
of  the  distorted  hairs  against  the  cornea  produces  a  super- 


AFFECTIONS  OF  THE  EYELASHES.          113 

ficial  keratitis  with  permanent  impairment  of  vision  in 
some  cases.  The  treatment  is  depilation.  The  hairs  should 
be  removed  as  often  as  they  appear. 

FIG.  48. 


TRICHIASIS. 

ALOPECIA  is  a  falling  out  of  the  lashes  due  to  granular 
conjunctivitis,  blepharitis  marginalis,  or  to  constitutional 
disease  (syphilis).  The  predisposing  cause  should  be  ascer- 
tained and  treated. 

FIG.  49. 


PEDICULUS  PUBIS,  crab-lice  in  the  cilia%  are  sometimes 
found  in  those  who  are  filthy  in  their  persons  and  surround- 
ings. They  cause  intolerable  itching,  which  is  relieved, 


114 


A    MANUAL   OF    CLINICAL   OPHTHALMOLOGY. 


and  the  crabs  destroyed,  by  the  daily  application  to  the 
free  margin  of  the  lids  of  the  yellow  oxide  of  mercury 
ointment. 

ACQUIRED    DEFORMITIES. 

KNTROPION  (Fig.  50)  is  a  partial  or  complete  inversion  of 
the  ciliary  margin  of  the  lid.  It  is  sometimes  noticed  as 
the  temporary  result  of  spasm  of  the  orbicularis  muscle, 
induced  by  the  long-continued  application  of  a  pressure- 
bandage  after  operations,  but  is  more  often  found  as  a  per- 

FIG.  50. 


ENTROPION  OK  LOWER  LIDS. 


manent  deformity,  caused  by  atrophy  of  the  conjunctiva 
and  consequent  abnormal  convexity  of  the  tarsal  cartilage, 
from  granular  conjunctivitis,  or  traumatism.  The  affection 
is,  in  a  large  majority  of  cases,  complicated  by  vascular 
inflammation  of  the  cornea,  and  of  the  conjunctiva  of  the 
inverted  lid.  Temporary  entropion  is  relieved  by  drawing, 
and  holding,  the  edge  of  the  lid  outward  by  adhesive 
strips  fastened  to  the  neighboring  skin.  Many  operations 
have  been  devised  for  the  permanent  cure  of  entropion, 
which  is  not  easily  remedied.  Advancement  of  the  tendon 


ACQUIRED    DEFORMITIES.  115 

of  the  palpebral  muscle  has,  in  our  hands,  given  the  best 
results. 

ECTROPION  (Fig.  51)  is  a  partial  or  complete  eversion  of 
the  margin  of  the  lid,  and,  like  entropion,  is  sometimes 
found  as  a  transient  symptom  of  inflammatory  swelling  of 
the  lid,  or  as  a  permanent  deformity  from  paralysis  .of 
the  orbicularis  muscle.  It  is,  however,  most  frequently 
caused  by  cicatricial  contraction  of  the  palpebral  or  neigh- 
boring integument,  the  result  of  destructive  injuries,  such  as 
burns,  wounds,  etc.,  involving  these  parts.  When  of  long 

FIG.  51. 


ECTROPION  OF  LOWER  LID. 

standing,  the  exposed  conjunctiva  becomes  hypertrophied. 
From  eversion  of  the  puncta  lacrymalia,  tears  collect  in  the 
conjunctival  sac,  and  flow  over  the  cheek,  causing  still  more 
irritation.  If  the  upper  lid  is  affected,  the  cornea  may  suffer 
from  adhesion  of  particles  of  dust.  In  the-  transient  form, 
recovery  of  the  normal  position  of  the  lid  ensues  when  the 
cause  is  removed.  In  the  permanent  form,  a  plastic  opera- 
tion is  the  only  measure  by  which  relief  can  be  obtained. 

BLEPHAROSPASM    is   an    involuntary  closure  of  the  lids 
from  tonic  or  clonic  spasm  of  the  orbicularis  muscle.     The 


Il6  A    MANUAL   OF   CLINICAL   OPHTHALMOLOGY. 

abnormal  contraction  of  this  muscle  is  reflex,  excited  by 
photophobia,  foreign  body  in  the  cornea,  neuralgia,  and 
by  accommodative  or  muscular  strain.  The  condition  may 
manifest  itself  by  an  occasional  twitching  of  the  lids,  so  slight 
as  to  be  hardly  noticeable,  local  chorea,  or,  by  the  forcible 
closure  of  the  lids,  lasting  a  considerable  length  of  time. 
The  cause  should  be. ascertained  and  relieved.  In  young 
persons,  the  defect  will  be  found,  in  many  cases,  to  be  due 
to  an  error  of  refraction,  or  muscular  anomaly,  correction 
of  which  will  result  in  a  cure  of  the  spasm.  Division  of 
the  supraorbital  nerve  has  been  advised  in  otherwise  in- 
tractable cases.  If  the  affection  is  found  to  be  clue  to  some 
constitutional  dyscrasia,  remedies  addressed  to  the  general 
system,  rather  than  to  the  local  manifestation,  will,  of  course, 
be  indicated. 

BLEPHAROPHIMOSIS  is  a  narrowing  of  the  palpebral  fissure, 
consequent  upon  long  continued  inflammation  of  the  con- 
junctiva. The  proper  length  of  the  commissure  should  be 
restored  by  the  operation  of  canthotomy  or  canthoplasty. 

PTOSIS  is  a  drooping  of  the  upper  lid  from  paralysis  of 
the  levator  palpebrai  muscle,  or  from  an  increase  in  weight 
of  the  lid  in  chronic  thickening  and  induration.  The 
former,  is  a  symptom  of  central  or  spinal  disease,  when  not 
due  to  an  affection  of  the  orbit.  Iodide  of  potassium,  mer- 
cury, strychnia  and  electricity,  are  proper  remedies  to  em- 
ploy when  the  initial  lesion  is  in  the  cerebro-spinal  system. 
Surgical  interference  is  warranted  under  the  same  condi- 
tions that  govern  operations  for  paralytic  strabismus. 

SYMBLEPHARON  (Fig.  52)  is  a  cicatricial  adhesion,  partial 
or  total,  of  the  lid  to  the  eyeball,  the  sequel  of  destructive 
inflammation  of  the  conjunctiva  from  burns  or  extensive 
ulceration.  It  is  relieved  by  operation. 

ANYKLOBLEPHARON  (Fig.  53)  is  a  union  of  the  free  mar- 


DISEASES    OF   THE    LACRYMAL   APPARATUS.  1 1/ 

gins  of  the  lids  from  traumatism  or  ulceration.     Trauma- 
tism   severe  enough  to  cause  complete  adhesion  between 

FIG.  52.  FIG.  53. 


SYMBLPEHARON.  ANKYLOBLKPHARON. 

the  ciliary  margin  of  the  lids,  will  also  destroy  the  cornea, 
and  treatment,  under  these  conditions,  is  unavailing. 


DISEASES  OF  THE  LACRYMAL  APPARATUS. 

HYPERTROPHY  of  the  lacrymal  gland,  the  position  of 
which  is  shown  by  dotted  line,  Fig.  54,  is  occasionally 
met  with  in  young  persons  as  a  small,  movable  tumor 
situated  in  the  upper  and  outer  angle  of  the  conjunctival 
sac.  It  is  not  attended  by  pain,  or  other  signs  of  inflam- 
mation, but  the  eyeball,  against  which  it  rests,  is  pressed 
downward  and  inward,  causing  double  vision,  the  chief 
symptom  of  which  the  patient  complains.  The  treatment 
consists  in  the  free  administration  of  tonics,  such  as  the 
syrup  of  the  iodide  of  iron,  cod-liver  oil,  etc.,  and  in  a 
nourishing  dietary. 

ABSCESS  of  the  lacrymal  gland  is  a  rare  affection,  usually 
chronic,  and  is  the  result  of  injuries,  and  of  chronic  inflam- 
mations of  the  conjunctiva.  Its  presence  is  determined  by 


Il8  A    MANUAL   OF   CLINICAL   OPHTHALMOLOGY. 

a  fluctuating  swelling  at  the  site  of  the  gland.  It  has  a 
tendency  to  rupture  through  the  skin,  causing  fistule,  and 
should  be  incised  as  soon  as  fluctuation  is  determined. 

FISTULE  of  the  lacrymal  gland  is  the  sequel  of  an  abscess 
that  has  opened  spontaneously.  It  remains  patulous  be- 
cause of  the  constant  discharge  through  it  of  tears 
mingled  with  pus.  The  opening  thus  formed  should  be 
closed  by  cauterization,  and  a  new  one  made  into  the  con- 

junctival  sac. 

Fie;.  54. 


LACRYMAL  GLAND. 

MALPOSITION,  or  diversion  of  the  puncta  lacrymalia,  which 
normally  lie  in  contact  with  the  conjunctiva  of  the  ball, 
prevents  the  escape  of  tears  which  collect  in  the  conjunc- 
tival  sac,  giving  rise  to  epiphora,  or  watery  eye.  The  con- 
dition is  brought  about  by  paralysis  of  the  orbicularis 
muscle,  chronic  thickening  and  eversion  of  the  lid  from 
conjunctivitis,  and  by  the  other  causes  of  ectropion.  If  the 
normal  position  of  the  lid  cannot  be  re-established  by 
massage,  slitting  up  of  one  or  both  canaliculi,  with  their 
permanent  transformation  into  gutters,  will  afford  partial 
relief. 


DISEASES    OF   THE    LACRYMAL   APPARATUS.  119 

STRICTURE  of  the  nasal  duct  may  form  in  any  part  of  its 
course,  but  the  junction  of  the  bony  and  cartilaginous  por- 
tions is  usually  the  site.  It  is  caused  by  chronic  inflam- 
mation of  the  conjunctiva,  or  of  the  Schneiderian  mucous 
membrane  of  the  nostrils,  lessening  the  lumen  of  the  canal. 
Its  constant  and  annoying  symptom  is  epiphora.  A  small 
swelling  is  common  on  the  site  of  the  lacrymal  sac,  which 
by  pressure  exudes  tears  and  mucus  backward  through 
the  canaliculi. 

Blennorrhcea,  Dacryocystitis,  abscess,  and  fistule  of  the 
lacrymal  sac,  are  common  sequelae  of  stricture. 

(a)  BlennorrlicEa. — The  mucous  lining  of  the  sac  becomes 
inflamed  from  the  presence  and  pressure  of  retained  tears, 
forming  a  small  tumor  which  exudes,  when  compressed,  a 
glairy  fluid  (tears  and  mucus  mingled)  into  the  conjunctival 
sac,  or  downward  through  the  stricture  into  the  nostrils. 
This  stage  of  the  affection  is  termed  mucocele. 

(ft)  Dacryocystitis  is  a  purulent  inflammation  of  the 
lacrymal  sac,  following  blennorrhcea  as  a  later  consequence 
of  stricture,  characterized  by  greater  tumefaction,  and  by  a 
discharge  largely  composed  of  pus,  which  the  patient  is 
compelled  to  express  many  times  in  the  course  of  the  day. 
Complaint  is  made  of  constant  overflow  of  tears,  pain  and 
swelling  at  or  near  the  inner  angle  of  the  lid,  and  of  dis- 
turbed function. 

(c)  Abscess  is  the  culmination  of  an  acute  dacryocystitis, 
and  is  manifested  as  a  rapidly  developing  inflammation  of 
the  lacrymal  sac  with  extensive  invasion  of  the  surrounding 
parts,  such  as  oedema,  redness,  and  excessive  swelling  of 
the  lids,  so  great  in  some  instances  as  to  produce  closure 
of  the  commissure.  The  sac  is  exceedingly  sensitive  to 
pressure,  and  the  abscess,  if  allowed  to  pursue  its  course 


I2O  A    MANUAL   OF    CLINICAL   OPHTHALMOLOGY. 

uninterruptedly,  will  eventuate  in  necrosis  of  the  bone,  and 
in  a  fistulous  opening  through  the  skin. 

((f)  Fistnlc(Y\g.  55)  is  the  establishment  of  a  pathological 
channel  from  the  lacrymal  sac  to  the  cutaneous  surface, 
through  which  the  products  of  inflammation  are  discharged. 

Treatment. — In  the  earlier  stages  of  stricture,  massage 
and  the  local  application  to  the  conjunctiva  of  astringents, 
injected  by  lacrymal  syringe  into  the  canaliculi,  or  simply 

FIG.  55. 


FISTULE  OK  LACRYMAL  SAC. 

dropped  into  the  conjunctival  sac,  may  be  sufficient  to  abort 
the  disease.    The  following  is  a  useful  lotion  for  the  purpose : 

R .     Boric  acid, gr.  v 

Zinc  sulphate, gr.  j 

Water *j. 

When  it  is  clearly  established  that  medication  alone  will 
not  bring  about  a  cure,  the  stricture  must  be  either  dilated 
or  divided.  This  method  of  treatment  is  not  in  all  cases 
satisfactory,  and  should  be  employed  only  when  other  and 


DISEASES    OF   THE    LACRYMAL   APPARATUS.  121 

less  radical  measures  have  proved  to  be  unavailing.  When, 
however,  the  swelling  at  the  site  of  the  gland  contains  pus, 
as  well  as  tears  and  mucus,  the  operation  can  no  longer 'be 
delayed  with  safety  to  the  patient,  or  with  credit  to  the 
surgeon.  The  local  application  of  lead  water  and  laudanum, 
leeches,  attention  to  the  bowels,  kidneys  and  skin,  may 
abort  an  abscess  during  its  formative  stage.  When  the 
tumor  shows  a  tendency  to  point  it  must  be  freely  incised. 
No  attempt  to  pass  a  probe  is  advisable  until  the  swelling 
and  tenderness  have  subsided ;  it  may  then  be  treated  as  a 
stricture.  The  fistulous  opening  will  usually  close  without 
direct  medication  when  the  normal  passage  for  the  escape 
of  tears  has  been  re-established ;  if,  however,  the  natural 
process  of  healing  is  too  slow,  union  may  be  promoted  by 
cauterization  of  the  walls  of  the  fistule.  When  it  is  not 
convenient  for  the  patient  to  see  the  surgeon  every  day  or 
two,  a  substitute  for  frequent  probing  is  the  leaden  or  silver 
style,  which  may  be  introduced  and  allowed  to  remain  in 
the  duct  for  several  weeks  or  months,  for  the  purpose  of 
keeping  the  stricture  dilated. 


PART  VII. 

DISEASES  OF  THE  CORNEA  AND  OF  THE 
SCLERA. 

In  corneal  inflammations,  the  surrounding  minute  vessels, 
straight  and  parallel  (terminals  of  larger  conjunct! val  and 
subconjunctival  vessels,  which  in  health  are  empty  of 
blood  and  invisible),  are,  with  few  exceptions,  injected. 
This  zone  of  vascularity  is  known  as  the  pcricorneal  ring. 
Inflammations  of  the  cornea  (corneitis,  keratitis)  are  divided 
into  two  classes,  superficial  and  deep. 

SUPERFICIAL  AND  VASCULAR. 

In  vascular  inflammations  of  the  cornea,  newly  formed 
arteries  and  veins,  given  off  from  the  conjunctival  vessels, 
ramify  over  the  corneal  epithelium.  These  vessels  vary 
in  size,  length  and  number,  involve  a  part  or  the  entire 
surface  of  the  cornea,  appear  early  or  late  in  the  course 
of  the  disease,  and  may  become  entirely  absorbed  without 
leaving  a  trace. ' 

PHLYCTENULE  (Fig.  56). — Phlyctenular  keratitis  is  charac- 
terized by  the  presence  of  one  or  more  small  cysts,  which 
form  on  the  limbus  cornea,  or  in  any  other  part  of  its 
surface,  containing  serum  and  lymph  cells.  The  outer 
wall  of  the  cyst  is  formed  by  the  corneal  epithelium. 
After  the  lapse  of  a  few  days,  the  bleb  breaks  through  its 
epithelial  wall  and  its  contents  escape,  leaving  an  ulcer. 
In  a  few  hours  after  the  appearance  of  the  phlyctenules, 

122 


PHLYCTENULAR    KERATITIS. 


123 


vascular  offshoots  from  the  conjunctiva  pursue  a  tortuous 
course  to  the  diseased  spot  or  spots.  There  is  usually  a 
leash  of  these  vessels,  four  or  five  in  number,  with  its  base 
on  the  limbus  and  its  apex  in  the  phlyctenule.  The  disease 
manifests  itself  oftenest  in  children,  especially  those  who 
have  inherited  a  scrofulous  diathesis,  and  is  developed  by 
improper  nourishment,  poor  sanitation,  and  reflex  disturb- 
ances (teething,  worms,  etc.). 

The  main  symptoms  are  photophobia,  lacrymation,  and 
acute  pain.  The  blister,  characteristic  vascularity,  and  re- 
sulting ulcer  sufficiently  mark  the  disease.  If  the  phlyc- 

FIG.  56. 


PHLYCTENULAR  ULCER. 

tenule  is  single,  it  is  usually  found  on  the  cornea  in  front  of 
the  pupil,  or,  if  multiple,  is  manifested  as  a  series  of  pin- 
point cysts  or  ulcers  on  limbus.  The  disease  disappears 
without  trace  or  sequelae  in  ten  or  fifteen  days,  under  proper 
treatment,  which  consists  in  restricting  the  diet,  regulating 
the  bowels,  and  in  the  use,  locally,  of  yellow  ointment  and 
atropine. 

HERPES  is  an  accompaniment  of  catarrhal  disease  of  the 
respiratory  and  intestinal  tracts.  One  or  more  vesicles 
form  on  the  cornea,  in  any  situation,  rupture  and  leave  an 
ulcer  with  transparent  floor,  and  clear  cornea  surrounding 
it,  or,  if  infected  by  micro-organisms,  the  base  of  the  ulcer 


124  A    MANUAL   OF    CLINICAL   OPHTHALMOLOGY. 

is  yellow,  and  a  considerable  portion  of  the  surrounding 
cornea  infiltrated  and  destroyed.  It  should  be  treated  as 
an  ulcer. 

PANNUS  is  a  superficial  vascular  infiltration  of  the  cornea 
with  partial  destruction  of  its  epithelium,  caused  by  granu- 
lar conjunctivitis.  The  epithelial  layer  of  the  cornea,  usu- 
ally the  superior  half,  in  some  instances  the  entire  surface, 
is  traversed  by  a  leash  of  blood-vessels  given  off  from  the 
conjunctival  arteries  and  veins.  These  newly-formed  and 
tortuous  vessels,  largest  at  the  periphery,  are  directed 
toward  the  centre  of  the  cornea.  There  may  be  only  a 
single  vessel,  or  the  entire  corneal  surface  may  be  trans- 
formed into  a  velvety,  beefy-looking  mass  with  temporary 
destruction  of  vision.  The  cause  is  due  either  to  friction 
of  the  roughened  lids  over  the  sensitive  corneal  epithelium, 
or  to  an  extension  into  the  cornea  of  the  true  granular  pro- 
cess. The  cornea  between  the  vessels  is  infiltrated  with 
lymph-cells,  and  on  its  surface  are  minute  facets  of  ulcera- 
tion.  These  pathological  changes  are  usually  limited  to 
the  anterior  layers  of  the  cornea,  do  not  often  involve  the 
structures  underlying  Bowman's  membrane,  and  affect 
primarily  the  cornea  underneath  the  upper  lid. 

Pain,  intolerance  of  light,  lacrymation,  swelling,  and  injec- 
tion of  the  conjunctival  and  ciliary  vessels,  are  the  usual 
symptoms.  Prognosis  is,  as  a  rule,  favorable,  notwith- 
standing the  long  duration  of  the  cause,  but  the  recurrent 
and  extensive  destruction  of  the  epithelium,  and  infiltration, 
lead  to  some  permanent  impairment  of  vision,  and,  in  some- 
cases,  to  conical  cornea,  and  to  corneal  staphyloma.  Treat- 
ment is  directed  to  the  granular  conjunctivitis,  which  is 
always  the  causes  of  pannus.  Atropine  and  hot-water  appli- 
cations, in  conjunction  with  the  treatment  of  the  granular 
lids,  are  useful. 


SUPERFICIAL  KERATIT1S.  125 

NON- VASCULAR  SUPERFICIAL  KERATITIS. 

HERPES  is  the  name  given  to  the  appearance,  in  groups 
on  the  cornea,  of  minute  round  vesicles  in  an  eye  already 
affected  by  catarrhal  conjunctivitis.  Calomel  dusted  into 
the  conjunctival  sac  is  the  only  treatment  required. 

OPHTHALMIC  HERPES  ZOSTER  is  the  formation,  during  an 
attack  of  frontal  herpes,  of  a  number  of  small  vesicles  on 
the  cornea.  These  vesicles  rupture,  form  ulcers,  and  leave 
opacities.  There  is  incomplete  anaesthesia- of  the  cornea. 
The  treatment  is  by  atropine,  pressure  bandage,  and  by  the 
internal  administration  of  quinine,  arsenic,  and  bismuth. 

RESORPTION  ULCER  is  a  superficial,  non-vascular  loss  ot 
corneal  substance  without  severe  symptoms.  The  pericor- 
neal  injection  is  not  marked.  The  ulcer  forms  in  an  eye 
previously  healthy,  or  in  one  which  is  already  the  seat  of 
corneal  or  conjunctival  disease.  The  bottom  of  the  ulcer 
nearly  always  remains  clear,  and  the  surrounding  tissue  is 
not  infiltrated.  The  disease  shows  little  tendency  to  in- 
volve the  iris.  Atropine  and  local  irritants,  are  the  reme- 
dies indicated. 

PROFOUND  KERATITIS. 

DEEP  ULCER  (Fig.  57)  is  inflammatory,  differing  from 
the  resorption  ulcer  in  its  involvement  of  the  deeper 
layers  of  the  cornea,  and  in  its  tendency  to  perforate.  It  is 
a  localized  loss  of  corneal  substance  attended  by  signs  of 
active  inflammation.  The  floor  and  margins  of  the  ulcer 
exhibit  a  yellowish  discoloration,  the  adjoining  parts  are 
infiltrated,  and  pus  forms  in  the  anterior  chamber  (Fig.  58), 
hypopyon,  or  there  is  a  collection  of  pus  in  the  most 
dependent  portion  of  the  cornea,  onyx.  The  inflammation 
is  acute,  the  pericorneal  and  conjunctival  injection  marked, 
and  iritis  may  complicate  the  affection  and  aggravate  the 
attending  symptoms — pain,  photophobia,  lacrymation,  and 


126  A    MANUAL   OF   CLINICAL   OPHTHALMOLOGY. 

loss  of  function.  The  prognosis  will  depend  on  the  si/ 
the  ulcer,  its  site,  and  on  the  severity  of  the  inflammatory 
process.  The  more  central  the  ulcer,  the  more  damaging 
it  will  be  to  vision.  All  deep  ulcers  of  the  cornea  leave  a 
permanent  cicatrix, — dense  and  white  when  complicated 
by  iritic  adhesion  (anterior  synechia). 

Treatment. — Atropine,  hot  water,  leeches  to  the  temple, 
saturated  solution  of  boric  acid,  applied  every  two  hours, 
repeated  and  persistent  cauterization  of  the  floor  and  sides  of 
the  ulcer  with  the  thermo-cautery,  or  silver  nitrate  (gr. 
xx-rij),  the  instillation  of  eserine  (gr.  ss-5j) every  two  hours 

FIG.  57.  FIG.  58. 


PERFORATING  ULCER  OK  THE  CORNEA, 

ADHESION  OF  IRIS  (ANTERIOR  SYNE-        ONYX  (6)  AND  HYI>OPYON  (4,  5). 
CHIA). 

during  the  day,  and  atropine  (gr.  iv-5j)  once  or  twice  during 
the  night,  are  indicated.  Eserine  is  employed  in  threatened 
perforation  to  contract  the  pupil,  thus  diminishing  intra- 
ocular pressure  and  supporting  the  tissues  behind  the 
diseased  cornea,  as  well  as  for  its  beneficial  local  action  on 
the  cornea  itself,  while  the  atropine  is  given  to  prevent 
maximum  contraction  of  the  iris  under  myotic  in- 
fluence, and  closure  of  the  pupil  by  exudation.  The  pressure 
bandage  may  be  employed.  When  spontaneous  perfora- 
tion is  imminent,  its  worst  features  may  be  avoided  by  in- 
strumental perforation.  The  treatment  after  perforation  is 


PROFOUND    KERATITIS.  I2/ 

by  antiseptic  washings  of  the  wound  with  a  saturated 
solution  of  boric  acid,  eserine,  and  by  a  pressure  bandage 
which  is  allowed  to  remain  undisturbed  for  4.8  hours.  The 
general  system  should  be  supported  by  tonics. 

SERPIGINOUS  ULCER  (Fig.  59)  is  a  destructive  purulent  in- 
filtration of  the  cornea  with  a  decided  tendency  to  advance 
in  extent  and  in  depth.  It  may  attack  any  portion  of  the 
cornea,  is  usually  longer  than  it  is  broad,  arc-shaped,  and  sur- 
rounded by  streaks  of  opacity  running  into  the  clear  cornea. 
The  ulcer  is  yellowish  in  color,  attended  by  moderate  signs 
of  inflammation,  and  not  infrequently  manifests  itself  in 
persons  whose  general  health  is  at  a  low  ebb.  It  is  often 

FIG.  59. 


ACUTE    SERPIGINOUS    ULCER  OF  CORNEA  WITH  CRESCENTIC   BORDER  OF 
INFILTRATION. 

associated  with  disease  of  the  conjunctiva  and  lacrymal  ap- 
paratus. Onyx,  hypopyon,  and  iritis,  are  frequently  present. 
The  treatment  is  the  same  as  that  given  for  other  forms  of 
deep  ulcer. 

INTERSTITIAL  or  PARENCHYMATOUS  KERATITIS  (Fig.  60)  is 
a  disease  involving,  as  its  name  suggests,  the  deeper  tissues 
of  the  cornea,  which  become  infiltrated  by  lymph  cells.  The 
appearance  of  the  cornea  is  that  of  a  piece  of  ground  glass. 
The  epithelium  is  partly  destroyed,  and  the  iris  lies  hidden 
behind  the  gray  opacity  thus  formed.  The  pericorneal 
injection  is  very  marked,  while  that  of  the  conjunctiva 


128  A    MANUAL   OF   CLINICAL   OPHTHALMOLOGY. 

is  either  slight  or  altogether  absent.  Vision  is  markedly 
reduced.  Photophobia  is  intense,  lacrymation  profuse, 
but  the  pain  slight;  indeed,  it  is  often  altogether  absent. 
The  disease  is  slow  and  insidious,  lasting  from  three  weeks 
to  many  months.  The  opacity  may  entirely  disappear, 
leaving,  in  the  more  favorable  cases,  irregularities  in  the 
corneal  curve,  or  becomes  dense  and  remains  permanently. 
The  iris  may  become  adherent  to  the  lens  capsule,  and 
occlusion  of  the  pupil  by  inflammatory  exudation  occur. 
In  the  severer  cases,  blood-vessels  are  formed  in  the  inter- 
stices of  the  cornea.  The  disease  occurs  among  scrofulous, 
syphilitic,  and  anaemic  young  subjects,  and  is  noted  by 
some  writers  as  a  symptom  of  inherited  syphilis. 

FIG.  60. 


INTERSTITIAL  KERATITIS. 

Treatment  is  by  atropine,  heat,  dry  or  moist,  locally,  and 
by  mercury,  iodide  of  potassium,  syrup  of  the  iodide  of  iron, 
and  other  tonic  remedies,  systemically.  The  patient's  eye 
should  be  protected  from  light,  but  not  from  the  atmosphere. 

ABSCESS  begins  as  a  single  or  multiple  collection  of 
grayish,  inflammatory  deposits  in  the  corneal  stroma, circum- 
scribed by  healthy  tissue  which  eventually  breaks  down, 
forming  a  single  large  cavity  containing  pus.  The  color 
now  changes  to  a  straw-yellow,  the  surrounding  cornea 
is  striated,  opaque,  and  bereft  of  its  epithelium.  Ilypo- 
pyon  and  onyx  are  common.  The  abscess  has  a  tendency 


PROFOUND    KERATITIS.  I  29 

to  increase  in  size  until  the  enveloped  pus  and  corneal  debris 
are  discharged  through  an  anterior  or  posterior  perforation. 
Iritis  of  severe  type,  is  a  usual  complication  of  corneal 
abscess,  which,  in  some  cases,  is  even  followed  by  capsular 
or  lenticular  cataract.  Iritic  adhesion  to  the  corneal 
cicatrix,  or  the  formation  of  anterior  synechiae,  is  a  common 
sequel  to  perforating  abscess,  just  as  it  is  to  perforating 
ulcer  not  preceded  by  collections  of  pus. 

Abscess  may  occur  as  a  result  of  traumatism,  purulent 
conjunctivitis,  the  exanthematous  fevers,  paralysis  of  the 
fifth  pair  of  cranial  nerves,  or  from  exposure,  alcoholic  ex- 
cesses, and  from  the  debility  of  old  age.  The  symptoms 
are  lacrymation,  pain,  photophobia,  and  loss  of  function. 

Treatment. — Alternate  instillations  of  atropine  (gr.  viij-5j) 
and  eserine  (gr.  j-5j),  as  directed  under  the  treatment  for 
ulcer,  should  be  employed,  and  the  eye  bathed  frequently 
with  a  solution  of  the  bichloride  of  mercury  (i  to  3000). 
When  the  abscess  threatens  to  perforate  spontaneously,  a 
free  instrumental  opening  should  be  made  by  Saemisch's 
incision.  After  the  escape  of  the  aqueous  and  collapse  of 
the  anterior  chamber  following  perforation,  the  cornea  must 
be  supported  by  a  pressure  bandage,  which  should  be  left 
undisturbed  for  seventy-two  hours,  except  in  blennorrhceal 
abscess,  when  the  treatment  is  mainly  directed  to  the  dis- 
eased conjunctiva. 

NEURO-PARALYTIC  KERATITIS  is  caused  by  pressure  upon, 
or  disease  of,  the  ophthalmic  division  of  the  fifth  nerve,  which 
has  become  paralyzed,  the  tissues  supplied  by  it  losing  their 
sensibility.  The  cornea  is  destroyed  through  loss  of 
nourishment,  disintegration  of  the  trophic  fibres,  or  from 
exposure  to  foreign  bodies,  air,  etc.  The  surgeon  should 
endeavor  to  remove  the  cause,  and  to  keep  the  lids  forcibly 
closed  throughout  the  continuance  of  the  disease. 


I3O  A    MANUAL   OF    CLINICAL   OPHTHALMOLOGY. 

NECROTIC  KERATITIS  is  a  rapid  destruction  of  the  cornea 
without  marked  signs  of  inflammation,  caused  by  maras- 
mus, and  other  exhaustive  diseases  of  infancy  and  early 
childhood. 

ARCUS  SENILIS,  Annulus  Senilis,  is  a  partial  or  complete 
ring  of  fatty  degeneration  of  the  cornea  about  1  mm.  from 
the  limbus. 

SEQUELS  OF  CORNEAL  INFLAMMATIONS. 
OPACITIES  OF  CORNEA. — A  nebula  is  a  faint,  macula  an 
easily  seen  but  translucent,  and  lencoma  a  dense,  white  opa- 
city of  the  cornea.    In  young  persons,  or  when  the  opacity  is 

FIGS.  6 1  AND  62. 


PARTIAL  STAPHYLOMA  OF  THE  CORNEA  AND  IRIS. 

recent,  absorption  may  be  induced  by  mild  irritants,  e.g., 
finely  powdered  calomel  dusted  against  the  cornea,  or 
yellow  ointment  applied  to  the  margin  of  the  lids  once  or 
twice  daily.  Eserine  (gr.  ss-5j)  dropped  into  the  conjunctival 
sac  daily,  may  also  prove  beneficial.  To  improve  vision,  an 
iridectomy,  opposite  clear  cornea,  may  be  made,  providing 
a  new  pupil  for  the  transmission  of  light. 

CONICAL  CORNEA  (Fig.  61)  is  a  thinning  and  cone-like 
projection  forward  of  the  cornea,  without  alteration  in  its 
transparency,  or  other  sign  of  inflammation.  It  is  a  chronic 


PROFOUND    KERATITIS.  13! 

and  slowly  progressive  affection,  the  result  of  inherent  weak- 
ness of  the  corneal  stroma.  It  commonly  occurs  in  persons 
between  fifteen  and  thirty  years  of  age,  and  is  first  sub- 
jectively noticed  by  a  deterioration  in  vision,  about  which 
the  patient  will  consult  the  surgeon.  The  condition  is 
detected  by  the  use  of  Placido's  disc,  or  by  the  distorted 
image  of  a  window  frame  on  the  patient's  cornea,  as  well 
as  by  retinoscopy,  in  which  the  shadow  is  broken  into  a 
series  of  circular  rings,  and  by  the  ophthalmoscope,  which 
shows  a  varying  degree  of  myopia  as  the  gaze  is  directed 
through  different  parts  of  the  cornea.  The  general  refrac- 

FIG.  63. 


TOTAL  STAPHYLOMA  OF  THE  CORNEA  AND  IRIS. 

tion  is  myopic,  but  a  minus  spherical,  or  a  combination  of  a 
minus  spherical  and  a  minus  cylindrical  glass,  will  be  found 
to  be  of  very  little  service,  since  the  cornea  has  many  radii 
of  curvature.  Treatment  is  of  very  little  value,  either  by 
correcting  the  refraction,  or  by  operation. 

STAPHYLOMA  (Figs.  62  and  63)  is  a  bulging  forward  of 
the  opaque  cornea,  which  has  been  so  weakened  by  disease 
that  it  gives  way  to  the  normal  pressure  of  the  intraocular 
fluids.  It  involves  a  part,  or  all  of  the  cornea,  according  to 
the  intensity  of  the  inflammation  of  which  it  is  a  sequel. 


132  A    MANUAL   OF   CLINICAL   OPHTHALMOLOGY. 

Frequently  the  iris  and  lens  are  dislocated  forward  into  the 
deepened  anterior  chamber,  the  former  adhering  to  the 
posterior  surface  of  the  staphyloma,  and  the  latter  becom- 
ing opaque.  Secondary  glaucoma,  with  ciliary  staphyloma, 
are  not  uncommon  complications,  and  blindness  more  or 
less  complete  is  the  rule.  Treatment  is  unavailing.  Am- 
putation of  the  cornea  or  enucleation  of  the  ball  is  indicated 
when  the  disfigurement  is  great,  or  the  suffering  severe.  In 
children  Critchett's  operation  is  advisable,  since  the  remain- 
ing stump  includes  two-thirds  of  the  ball,  and  does  not 
prevent  development  of  the  lines  of  the  orbit,  as  does  an 
enucleation  performed  in  early  life. 

TUMORS  of  the  cornea  usually  occur  as  extensions  of  in- 
flammatory new  formations  from  the  conjunctiva,  or  from 
the  deeper  orbital  tissues.  Dermoid  cysts,  melanoma,  pig- 
mented  sarcoma,  and  melanotic  cancer  may  grow  directly 
from  the  cornea.  The  treatment  is  by  excision  or  enuclea- 
tion of  the  ball.  Recurrence  of  these  growths  is  probable. 


DISEASES  OF  THE  SCLERA. 

SCLERITIS  is  a  localized  inflammation  of  the  scleral  tissue, 
rheumatic  in  origin  as  a  rule,  characterized  by  slight  swell- 
ing, pain  on  pressure,  active  injection  of  contiguous  ciliary, 
deep  pericorneal  and  conjunctival  vessels,  which  impart  to 
the  diseased  area  a  purplish  hue.  There  are  no  signs  of 
corneal  or  iritic  involvement.  The  localized  swelling  and 
redness,  and  rheumatic  history,  render  the  diagnosis  easy. 
The  course  of  the  disease  is  protracted,  relapses  frequent, 
and  the  pain  severe.  There  may  be  temporary  loss  of 
function. 

Treatment. — Dry  heat  locally,  salicylates,  phosphate  of 
sodium  by  the  stomach,  and  confinement  of  the  patient 


DISEASES    OF   THE   SCLERA.  133 

to  warm  apartments,  in  which  the  light  is  subdued,  are 
indicated. 

STAPHYLOMA  (Fig.  64). — Anterior  staphyloma,  or  ciliary 
staphyloma,  is  a  bulging  outward  of  the  sclera  in  the 
ciliary  region,  the  result  of  long-continued  increased  intra- 
ocular pressure,  as  in  secondary  glaucoma,  and  involves  in 
its  distention,  the  underlying  portion  of  the  ciliary  body  or 
choroid.  The  sclera  becomes  gradually  thinner,  assumes 
a  bluish  discoloration,  and  the  portion  of  the  uveal  tract 

FIG.  64. 


STAI'HYLOMA  OF  SCLERA. 

involved  in  the  process  atrophies,  and  its  place  is  occupied  by 
inflammatory  exudations.  There  may  be  one  or  more  pea- 
sized  staphylomata,  or  the  entire  anterior  half  of  the  globe 
may  form  a  single  large,  staphylomatous  mass,  involving 
ciliary  body,  lens,  iris  and  cornea.  The  function  of  the 
eye  is  entirely  and  permanently  destroyed.  Amputation 
(Critchett's  operation),  or  enucleation  of  the  ball,  is  to  be 
performed,  when  the  tumor  is  large  enough  to  warrant 
surgical  interference. 

POSTERIOR  STAPHYLOMA  (Fig.  65). — The  pathogenesis  of 


134 


A    MANUAL   OF    CLINICAL   OPHTHALMOLOGY. 


bulging  of  the  sclera  (non-traumatic)  at  the  posterior  pole 
of  the  globe,  is  dissimilar  to  the  form  just  described.  It  is 
always  present  in  high  degrees  of  myopia,  and  its  growth  is 
dependent  on  the  same  causes  that  develop  myopia.  It  is 
a  true  distention  of  the  sclera,  adjacent  to  the  optic  nerve, 
preceded  by  absorption  of  the  choroid  which  so  weakens 
it,  that  it  cannot  maintain  its  normal  curve  against  the  intra- 
ocular pressure.  The  true  cause,  and  growth,  of  malig- 


nant  myopia,  whether  inherited  or  acquired,  are  associated 
with  weakness  of  the  sclera,  and  its  tendency  to  stretch, 
in  this  situation.  The  process  is  chronic  and  not  attended 
by  any  evidences  of  inflammation  in  the  sclera  or  adjoining 
coats.  The  staphyloma  is  at  once  seen  by  the  ophthalmo- 
scope as  a  white  placque,  limited  to  one  side  (temporal),  or 
surrounding  the  nerve  with  irregular  small  blotches  of 
pigment  distributed  over  its  surface,  traversed  by  retinal 


DISEASES    OF   THE    SCLERA.  135 

vessels.  It  is  more  or  less  distinctly  bounded  by  choroidal 
tissue.  Occasionally  in  advancing,  or  very  high  myopia, 
a  second  distention,  joined  to  the  first  by  a  small  ridge 
of  normal  sclera,  and  known  as  secondary  staphyloma, 
is  found.  Patches  of  atrophied  choroid  in  the  foveal  region, 
detached  from  the  staphyloma,  are  not  unusual. 


PART  VIII. 

DISEASES    OF   THE   CRYSTALLINE  LENS  AND 
LENS   CAPSULE. 

LENTICULAR   OPACITIES. 

CATARACT  is  an  opacity  of  the  lens,  either  congenital  or 
acquired,  and  under  these  two  heads  the  various  forms  of 
cataract  are  divided. 

CONGENITAL  CATARACT  is  a  development  during  intra- 
uterine  life,  as  a  consequence  of  anomalous  structure  or  of 
embryonic  disease,  of  certain  distinctive  opacities,  which 


POSTERIOR  POLAR  CATARACT. 

have  been  classified  and  described  under  the  following  ap- 
propriate headings : — 

(a]  CENTRAL  CATARACT  is  a  small,  round,  dense  white 
spot  in  the  nucleus. 

(b)  ANTERIOR   POLAR   CATARACT   is   an   aggregation  of 
numerous   minute  points  of  opacity  grouped  around  the 
anterior   extremity   of  the    axis    of  the    lens,    sometimes 
associated   with,  and    dependent   on,  pyramidal    capsular 
cataract  (exudation  from  the  iris). 

136 


DISEASES    OF    THE    LENS.  137 

(c]  POSTERIOR   POLAR  CATARACT  is  a  similar  opacity  at 
the  posterior  pole  of  the  lens,  produced,  probably,  by  the 
premature  abolition  of  the  hyaloid  artery.     Anterior  and 
posterior  polar  cataract  frequently  co-exist  in  the  same  lens, 
and  may  be  united  by  a  line  of  opacity  (fusiform  cataract). 

(d)  ZONULAR  or  LAMELLAR  CATARACT,  the  form  most  fre- 
quently found,  is  an  opacity  involving  one  or  more  layers  or 
strata  of  the  lens  about  half-way  between  the  periphery  and 
nucleus,   the   portions  within   and    without   this  ring  re- 
maining transparent.     The  opaque  lamella  is  seen  by  the 
ophthalmoscope  to  be  of  a  dull  gray  color,  sharply  defined 
from  the  surrounding  clear  cortex,  through  which  an  indis- 
tinct  view  of  the   fundus   can   sometimes   be    had.     The 
diagnosis  is  easily  made  when  the  pupil  is  dilated. 

TOTAL  CONGENITAL  CATARACT. — The  lens  is  either  en- 
tirely opaque  at  birth,  or  opaque  in  its  centre,  the  opacity 
rapidly  advancing  during  the  first  few  months  of  extra- 
uterine  life,  in  the  latter  case,  until  the  whole  lens  is  opaque. 
The  lens  is  at  first  soft  and  of  normal  size,  but  eventually 
shrinks  and  hardens  from  calcareous  transformation.  It  is 
usually  hereditary. 

It  is  of  interest  to  know  that  while  the  varieties 
of  cataract  described  above  are  in  the  majority  of  cases 
congenital,  others,  that  resemble  them  in  every  way,  are 
acquired  through  traumatism,  local  inflammations,  and 
general  disease,  such  as  rachitis,  convulsions,  etc.  Con- 
genital cataract  may  be  monocular  or  binocular.  The 
acuity  of  vision  in  any  given  case,  will  depend  on  the  degree 
and  extent  of  opacity  in  the  pupillary  area.  Some  subjects 
are  enabled  to  pass  through  the  school  period,  learning  to 
read,  write,  etc.,  while  others  will  be  enabled  to  distinguish 
large  objects  only.  Late  in  life,  congenital  cataracts  are 


138  A    MANUAL   OF   CLINICAL  OPHTHALMOLOGY. 

inclined  to  become  wholly  opaque.  The  "treatment  is  by 
discission,  or  iridectomy. 

ACQUIRED  CATARACT. — Traumatism,  local  inflammations, 
and  debilitating  constitutional  affections,  may  produce  catar- 
act at  any  age.  The  pathological  process  is  primarily  a  dis- 
turbance of  nutrition,  and  secondarily  a  disturbance  of  the 
anatomical  relations  of  the  strata  of  the  lens — absorption 
of  the  fluid,  and  sclerosis  of  its  fibrous  elements.  In  young 
individuals,  twenty-five  to  thirty-five  years  old,  the  lens  is 
soft,  and  lenticular  opacities  occurring  in  persons  under  the 
age  of  thirty  years,  are  designated  "  soft "  cataracts,  while 
the  term  "  hard  "  cataract  is  applied  to  opacities  occurring 
in  older  persons. 

Traumatism,  perforating  corneal  ulcer,  chronic  iritis  and 
cyclitis,  choroiditis,  detachment  of  the  retina,  retinitis  pig- 
mentosa,  and  diabetes,  are  among  the  ascertained  causes 
of  cataract  in  the  young.  Treatment :  discission. 

SENILE  CATARACT. — The  word  senile  is  employed  to  de- 
scribe opacities  occurring  in  persons  of  greater  age  than 
thirty  years,  and  which  can  be  ascribed  only  to  senile 
change.  Of  course,  the  causes  that  are  operative  in  the 
production  of  cataract  in  the  young,  are  also  operative  in 
its  production  in  older  persons,  and  cataracts  thus  pro- 
duced are  not,  properly  speaking,  senile,  but  secondary — 
secondary  to  traumatism,  or  to  disease. 

Senile  cataract  is  either  "  incipient"  or  "  mature."  The 
former  is  said  to  be  nuclear  when  its  starting  point  is  in  the 
centre,  and  cortical  when  the  opacity  begins  in  the  pe- 
riphery of  the  lens. 

It  may  be  observed,  in  connection  with  the  natural  his- 
tory of  cataract,  that  a  myopia  of  3"  or  4",  due  to  swelling 
of  the  lens,  usually  precedes  the  loss  of  transparency.  The 


CONGENITAL  LAMELLAR  CATARACT. 
(DILATED  PUPIL). 


CONGENITAL  LAMELLAR  CATARACT  ADVANC- 
ING TO  TOTAL  (DILATED  Pui-n  . 


INCIPIENT  NUCLEAR  CATARACT 
(DILATED  PUPIL). 


INCIPIENT  NUCLEAR  AND  CORTICAL 
CATARACT  (DILATED  PUPIL). 


CORTICAL  CATARACT  (DILATED  PUPIL).     CORTICAL  CATARACT  (UNDILATED  PUPIL). 


CONGENITAL  CAPSULAR  CATARACT 
(DILATED  PUPIL). 


IRREGULAR  LENTICULAR  AND  CAPSULAR 
CATARACT  (DILATED  PUPIL). 


DISEASES    OF   THE    LENS.  143 

opacity  commences  as  a  few  short  streaks,  seen  as  dark  lines 
by  the  ophthalmoscope,  in  the  cortex  at  the  line  of  union 
of  the  different  lens  segments,  or  as  a  circular  dark  body 
limited  to  the  nucleus,  the  process  advancing  by  involvement 
of  neighboring  clear  tissue  until  the  entire  lens  is  included. 
The  period  of  growth  from  incipiency  to  maturity  varies  in 
different  cases.  It  may  be  completed  in  a  few  months 
or  in  the  longer  lapse  of  years.  Mature  cataract  becomes 
hypermature  by  a  further  tissue  metamorphosis,  the  cortex 
becoming  fluid,  the  fibres  broken  and  irregular,  and  the 
lens  shrunken,  and  infiltrated  with  myelin,  cholesterin,  and 
calcareous  formations. 

Among  the  clinical  features  of  cataract,  it  may  be  noted 
that  one  eye  is,  as  a  rule,  first  affected,  its  fellow  following 
in  the  morbid  process  after  a  varying  lapse  of  time.  The 
patient  suffers  no  pain,  and  consults  the  surgeon  for  the 
relief  of  gradually  failing  sight,  which  is  very  likely  attributed 
to  the  lack  of  proper  glasses.  All  objects  are  seen  through  a 
veil  or  mist  which  increases  to  blindness,  or  perception  of 
light  only,  with  increasing  and  .finally  complete  opacity  of 
the  lens.  Such  patients  will  very  often  not  seek  advice  until 
the  second  eye  is  affected.  By  oblique  illumination,  the  lens 
will  show  dark  streaks,  or  areas,  behind  the  pupil.  By  the 
ophthalmoscope,  the  opacity  is  clearly  outlined  against  the 
red  reflex  of  the  fundus  until  the  cataract  is  very  nearly 
matured.  The  opacity  is  fixed,  moving  only  with  the 
movement  of  the  ball  (diagnosis  between  lenticular  and 
vitreous  opacity),  and  is  seen  immediately  behind  the  pupil. 

A  cataract  is  "  ripe,"  and  ready  for  operation,  when,  by 
oblique  illumination,  the  opacity  is  seen  on  a  plane,  or 
nearly  on  a  plane,  with  the  pupillary  margin,  when  vision 
is  reduced  to  the  perception  of  large  moving  objects,  such 


144  A    MANUAL   OF   CLINICAL   OPHTHALMOLOGY. 

as  the  hand,  twelve  inches  away  from  the  eye,  and  when 
light  projection  is  possible  in  all  parts  of  the  visual  field. 
(Patient  is  directed  to  look  straight  forward,  and  correctly 
give  the  position  of  the  light  as  it  is  moved  by  the  surgeon 
in  the  different  situations.  This  the  patient  will  only  do 
when  there  is  no  serious  defect  of  the  eye  ground.)  K\- 
ceptionally,  cataracts  should  be  extracted  before  maturity. 
e.g.,  when  both  lenses  are  involved  to  the  extent  of  pro- 
hibiting the  necessary  occupation  of  life.  It  is  conservative 
surgery  to  operate  on  the  eye  first  affected,  when  both  are 
ripe. 

Treatment:  extraction.  Ninety  per  cent,  regain  useful 
vision. 

TRAUMATIC  CATARACT. — A  contusion  of  the  ball,  ruptur- 
ing the  lens  capsule,  disturbance  of  the  anatomical  arrange- 
ment of  the  layers  or  sectors  of  the  lens,  or  laceration  of 
its  capsule  by  a  foreign  body,  whether  or  not  the  lens  is 
pierced,  will  lead  to  a  partial  or  complete  opacity  of  the 
crystalline  body.  As  a  rule,  the  entire  lens  participates  in 
the  morbid  process.  Immediately  following  the  injury  one 
or  more  stripes  of  opacity  radiate  through  the  lens,  which 
swells  and  partly  protrudes  into  the  anterior  chamber,  where 
partial  absorption  takes  place.  Iritis  is  a  frequent  accom- 
paniment of  traumatic  cataract. 

Treatment :  in  young  subjects  the  lens  will  probably 
undergo  absorption  without  operation  ;  in  elderly  persons, 
it  must  be  extracted. 

DISLOCATION  OF  THE  LENS  may  exist  congenitally,  but 
it  is  more  often  acquired.  A  congenital  anomaly  of  the 
vitreous  or  choroid  is  the  underlying  cause  in  the  former, 
and  the  latter,  may  be  ascribed  to  contusions,  or  to  the  direct 
and  forcible  contact  of  a  foreign  body.  The  lens  substance 


DISEASES    OF   THE    CAPSULE    OF   THE    LENS.  145 

usually  becomes  opaque,  although  it  sometimes  retains, 
in  the  congenital  form,  its  transparency  for  many  years. 
No  treatment  is  advisable.  In  acquired  dislocation  of  the 
lens,  extraction  should  be  performed  when  possible. 

APHAKIA,  absence  of  the  lens,  is  most  frequently  met 
with  in  persons  upon  whom  discission  or  extraction  has 
been  performed.  The  diagnosis  is  made  by  the  history,  the 
appearance  of  the  eye, — deep  anterior  chamber,  trembling 
of  iris,  absence  of  the  small  inverted  image  of  a  candle  held 
a  short  distance  from  the  eye  (Purkinje's  sign),  high  degree 
of  hypermetropia,  and  by  the  loss  of  accommodation. 

Treatment :  glasses  for  far  and  for  near. 


DISEASES  OF  THE  CAPSULE  OF  THE  LENS. 

DEPOSITIONS  ON  THE  ANTERIOR  SURFACE  are  found,  such 
as  the  remains  of  the  embryonic  pupillary  membrane,  the 
exudation  from  iritis,  and  cicatrices  from  temporary  adhe- 
sions to  the  cornea,  following  perforating  ulcer.  On  the 
posterior  surface,  the  terminal  remains  of  the  hyaloid  artery, 
and  the  deposition  of  irregularly  shaped  flocculi,  precipi- 
tated from  the  vitreous,  are  occasionally  found. 

WOUNDS. — The  capsule  of  the  lens  may  be  lacerated, 
and  this  injury  is  followed,  in  young  persons,  by  retraction 
or  gaping  of  the  divided  margins,  produced  by  extrusion  of 
lens  matter,  and  by  partial  opacity  of  the  anterior  portion 
of  the  capsule.  Slight  wounds  of  the  capsule  in  elderly 
persons  are  inclined  to  heal.  Opacity  of  the  capsule 
anteriorly,  together  with  opacity  of  the  adjoining  lens, 
may  entirely  clear  up. 

SECONDARY  CATARACT  is  a  loss  of  transparency  of  the 
capsule  following,  in  a  few  weeks,  extraction  of  the  lens. 
13 


146  A    MANUAL   OF   CLINICAL   OPHTHALMOLOGY. 

Treatment. — When  the  opaque  capsule  occupies  the 
pupillary  space,  an  opening  should  be  made  in  its  centre  by 
means  of  two  needles,  or  by  division  with  a  small  sickle- 
shaped  knife  ;  or,  when  possible,  the  opaque  capsule  should 
be  extracted  through  an  opening  made  in  the  cornea  near  its 
scleral  margin. 


PART  IX. 

DISEASES  OF  THE  UVEAL  TRACT. 

CONGENITAL  ANOMALIES  OF  THE  IRIS. 

ANIRIDIA  is  an  absence  of  a  part,  usually  the  pupil- 
lary margin,  or  of  the  entire  iris.  It  is  an  uncommon 
affection,  and  is  found  associated  with  other  congenital 
defects,  such  as  posterior  polar  cataract,  or  microphthalmus. 

COLOBOMA  is  a  fissure  of  the  iris,  with  its  base  at  the 
pupillary  margin,  and  its  apex  at  or  near  the  periphery.  A 
similar  defect  in  the  ciliary  body  and  choroid  coat  often 
co-exists.  It  is  an  indication  of  arrested  development. 

PERSISTENT  PUPILLARY  MEMBRANE. — The  pupillary  space 
is  occupied  in  the  fcetus  by  a  thin,  web-like  membrane 
which  occasionally  remains  after  birth,  as  a  few  fine 
threads,  running  obliquely  across  the  pupil,  attached  to 
the  anterior  surface  of  the  iris.  They  might  easily  be 
mistaken  for  posterior  synechiae,  but  their  origin  from  the 
anterior  surface,  and  not  from  the  inner  pupillary  border, 
their  fineness  and  uniformity  of  outline  as  contrasted  with 
the  irregularly  shaped  and  dentated  inflammatory  adhe- 
sions, as  well  as  their  very  slight  influence  on  the  mobility 
of  the  iris,  will  determine  the  diagnosis. 

POLYCORIA  is  a  multiple  pupil,  formed  by  an  imperfect 
coloboma,  or  by  the  remains  of  a  persistent  pupillary  mem- 
brane, which  divides  the  otherwise  normal  pupil  into  two 
or  more  spaces  capable  of  contraction  and  expansion. 

ALBINISM  is  that  congenital  condition  in  which  the  uveal 

147 


148  A    MANUAL   OF    CLINICAL    OPHTHALMOLOGY. 

tract,  the  hair,  eye-brows  and  lashes,  contain  no  pigment 
cells.  When  the  subject  faces  a  bright  light,  the  red 
reflex  of  the  fundus  shows  through  the  pupil  and  inter- 
stices of  the  iris.  Indistinct  vision,  from  the  imperfect 
absorption  by  the  choroid  of  the  rays  of  light  and  from 
myopia,  congenital  or  acquired  from  the  necessity  of  hold- 
ing objects  close  to  the  eye,  and  photophobia,  are  invari- 
ably present 


DISEASES  OF  THE  IRIS. 

HYPER^EMIA   OF  THE  IRIS   is   an   abnormal  fullness    of 
its  vessels  preliminary  to  iritis,  or  accompanying  inflamma- 

FIG.  67. 


POSTERIOR  SYNECHIA. 

tion  of  the  cornea,  or  of  other  and  deeper-seated  portions 
of  the  eye.  It  is  recognized  by  the  presence  of  enlarged 
vessels  on  the  surface  of  the  iris,  its  indolent  response  to 
variations  of  light,  and  by  its  lessened  expansibility  under 
the  influence  of  mydriatics.  The  symptoms  of  hyperaemia 
are  those  of  the  disease  it  inaugurates  or  accompanies. 
PLASTIC  IRITIS  (Fig.  67). — The  conjunctiva  in  plastic  iritis, 


DISEASES    OF   THE    IRIS.  149 

the  most  common  inflammation  involving  the  iris,  is  usually 
inflamed  and  chemosed,  with  a  deep-seated  partial  or 
complete  pericorneal  zone  of  purplish  vascularity.  The 
iris,  which  also  shows  increased  vascularity,  is  discolored 
and  tumefied,  and  discharges  on  its  surface,  and  in  its  par- 
enchyma, a  tenacious  lymphoid  exudation,  which  quickly 
and  permanently  binds,  if  the  disease  is  left  uncontrolled, 
its  pupillary  border  to  the  anterior  surface  of  the  lens  cap- 
sule, thus  forming  posterior  synechia.  The  synechiae,  dis- 
colored by  an  intermixture  of  pigment  from  the  uveal  tract, 
visibly  project  in  ragged  edges  from  the  pupillary  margin. 
These  adhesions  may  unite  a  part  of  the  pupillary  border 
to  the  anterior  capsule  of  the  lens,  partial  synechia,  or  the 
entire  posterior  surface  of  the  lens  may  be  adherent  to  the 
lens  capsule  (total  or  complete  synechia),  annihilating  the 
posterior  chamber.  The  pupillary  space  may  be  in  part 
or  altogether  occluded  by  the  membranous  exudation,  and, 
in  such  instances  (they  are  not  infrequent),  the  capsule  imme- 
diately behind  this  space,  is  likely  to  become  opaque,  and 
the  mobility  of  the  iris  lost.  In  this  condition  its  response 
to  mydriatics,  is  nearly  or  completely  abolished,  and  the 
functions  of  the  eye  temporarily  destroyed  ;  for  vision  is 
diminished  in  proportion  to  the  extent  and  density  of  the 
exudation.  Pain  in  the  ball,  radiating  to  parts  supplied 
by  the  supra-orbital  and  infra-orbital  branches  of  the  fifth 
nerve,  is  felt.  Increased  lacrymation  and  intolerance  of 
light,  are  also  marked  symptoms.  Tension  remains  nor- 
mal. 'Sensitiveness  over  the  ciliary  region  is  excessive. 
The  disease  runs  a  course  of  from  two  to  six  weeks,  or  even 
longer.  Chronic  iritis  as  an  independent  affection  rarely,  if 
ever,  exists. 

The  word  "  chronic  "  as  applied  to  plastic  iritis,  has  refer- 
ence to  the  recurrent  acute  attacks,  which  are  prone  to  occur 


I5O  A    MANUAL   OF   CLINICAL   OPHTHALMOLOGY. 

from  a  disturbance  of  function  caused  by  attachments  be- 
tween iris  and  capsule,  or  from  chronic  inflammation  of  the 
neighboring  parts. 

Iritis  may  under  treatment  recover  without  sequelae ; 
usually,  however,  synechia  and  minute  patches  on  the  lens 
capsule,  mark  the  sites  of  adhesive  exudation,  and  vision 
may  be  destroyed  through  pupillary  occlusion.  It  is  not 
infrequently  found  that  a  complete  annular  synechia  re- 
mains, cutting  off  communication  between  the  anterior  and 
posterior  chambers  through  the  ordinary  pupillary  channel, 
and  secondary  glaucoma  is  the  natural  and  inevitable  con- 
sequence, unless  the  inter-pupillary  communication  is  re- 
established by  iridectomy.  It  is  the  duty  of  the  surgeon, 
when  the  existence  of  this  condition  is  definitely  determined, 
to  urge  this  operation,  and  to  refuse  to  treat  the  case  if  the 
patient  declines  its  immediate  performance. 

It  is  not  always  easy  to  determine  the  cause  of  plastic 
iritis.  It  is  consecutive  to  inflammation  primarily  in- 
volving any  portion  of  the  uveal  tract,  and  to  trauma- 
tism.  The  presence  of  a  foreign  body  may  set  up  a  plastic 
iritis,  or  it  may  arise  idiopathically.  The  common  cause 
of  the  disease,  are  syphilis,  gonorrhoea,  rheumatism,  and 
scrofula,  or  tuberculosis. 

Treatment  is  local  and  constitutional.  The  patient  should 
be  confined  to  a  properly  ventilated  but  darkened  room- 
Atropine  (gr.  viij-5j),  hot-water  bathing,  and  leeches  to  the 
temple,  are  to  be  employed,  and  actively  employed,  locally. 
If  the  disease  is  due  to  traumatism,  the  appropriate  local 
treatment  should  be  instituted;  if  the  outbreak  is  of  rheu- 
matic origin,  the  salicylates  are  indicated ;  if  syphilis  is  the 
cause,  the  patient  should  be  mercurialized  to  the  point  of 
mild  sali  vation,and  mercury  in  lessening  doses  with  the  iodide 
of  potassium,  administered  during  the  continuance  of  the 


DISEASES    OF   THE    IRIS.  151 

inflammation.  The  mercurials  may  be  omitted  if  the  affec- 
tion is  due  to  gonorrhoea.  In  a  word,  the  cause,  whatever 
it  may  be,  should  be  treated  on  general  principles,  inde- 
pendently of  the  local  affection,  the  patient's  strength  nour- 
ished, and  the  general  system  built  up  by  a  generous  dietary, 
tonics,  and  fresh  air. 

SEROUS  IRITIS,  DESCEMITIS  (Fig.  68),  is  recognized  by 
the  presence  on  the  posterior  surface  of  the  cornea  of  a 
collection  of  minute  points  of  exudation,  and  by  a  similar 
exudation,  combined  with  larger  and  denser  flakes,  floating 
in  the  anterior  portion  of  the  vitreous  chamber.  The  iris 
reacts  sluggishly  to  the  stimulus  of  light  and  accommo- 

FIG.  68. 


SEROUS  IRITIS. 

dation,  and  may  present  one  or  more  minute  posterior 
synechiae.  Light  does  not  pass  readily  through  the  floccu- 
lated cornea  and  vitreous,  and  there  is  a  resulting  deterio- 
ration of  vision.  The  details  of  the  fundus  are  indistinctly 
seen  by  the  ophthalmoscope.  The  nerve  is  ill-defined,  and 
the  retinal  vessels  veiled,  as  in  neuro-retinitis.  These 
appearances  are  due,  as  a  rule,  to  the  clouded  media,  but 
in  some  instances  are  the  results  of  a  co-existing  optic 
neuritis.  The  pain  and  injection  are  inconsiderable ;  they 
may,  indeed,  be  altogether  absent,  and  indistinct  vision  the 
symptom  of  which  the  patient  most  complains.  The  course 
of  the  disease  is  chronic,  its  etiology  obscure,  and  the  treat- 


152  A    MANUAL   OF   CLINICAL   OPHTHALMOLOGY. 

ment  unsatisfactory.  Mydriatics,  mercurials  and  the  iodides 
are,  however,  employed.  The  nutrition  of  the  lens  is  dis- 
turbed, streaks  of  opacity  appearing  in  the  cortex,  followed 
by  total  opacity  of  the  lens,  in  a  small  proportion  of  cases. 

PARENCHYMATOUS,  OR  SUPPURATIVE  IRITIS. — In  simple 
plastic  iritis,  exudation  from  the  inflamed  membrane  is 
largely  deposited  in  the  anterior  chamber  and  pupillary  space, 
but  in  parenchymatous  iritis,  the  inflammatory  exudates  are 
mostly  confined  to  the  tissues  of  the  iris,  which  become 
swollen  and  spongy  in  consequence,  and  its  color  changes 
to  a  yellow  or  greenish-yellow,  as  the  lymphoid  cells  un- 
dergo transformation  into  pus.  The  pupillary  border  of 
the  iris  is  hypertrophied  and  thickened  by  fibrinous  exu- 
dations, which  project  into,  and  sometimes  obliterate,  the 
pupillary  space.  The  characteristic  sign  of  purulent  iritis, 
is  the  deposition  in  the  anterior  chamber  of  pus,  which,  less 
consistent  and  more  fluid  than  the  hypopyon  of  keratitis,  is 
absorbed  and  re-formed  rapidly.  Commonly  there  is  a  for- 
mation in  one  or  more  sections  of  the  iris  of  small  collec- 
tions of  cells,  tuberculous  or  gummatous  according  to  the 
origin  of  the  disease.  Vision  is  generally  permanently  im- 
paired. The  treatment  is  practically  the  same  as  that  already 
given  for  the  plastic  form  of  iritis,  and  should  be  pushed 
energetically  and  persistently. 

MYDRIASIS,  DILATATION  OF  PUPIL,  is  (i)  Idiopathic  when 
it  persists  for  many  years  in  one  or  both  eyes,  or  alternates 
from  one  eye  to  the  other,  and  is  associated,  in  most  cases, 
with  paralysis  of  accommodation.  It  is  likely  to  obtain  in 
several  members  of  a  family,  and  exists  without  apparent 
cause  other  than  heredity.  (2)  It  is  artificial,  and  transient, 
when  the  result  of  the  instillation  of  a  mydriatic;  (3)  symp- 
tomatic when  it  is  the  reflex  of  a  lesion  in  the  brain  or  spinal 
cord,  or  from  intra-ocular,  or  extra-ocular  pressure;  (4)  cmo- 


DISEASES    OF   THE    IRIS.  153 

tional  when  due  to  anger,  fright,  or  nervous  excitement.  If 
the  mydriasis  is  long  continued,  the  local  instillation  of  eser- 
ine  may  be  beneficial.  If,  however,  the  mydriasis  is  due  to 
a  lesion  of  the  cerebro-spinal  system,  treatment  is  unavailing. 

MYOSIS,  CONTRACTION  OF  THE  PUPIL,  is  (i)  artificial  and 
transient,  when  the  result  of  the  instillation  of  a  myotic 
(eserine) ;  (2)  irritative  when  the  3d  nerve,  or  its  pupillary 
branch  is  excited  to  excessive  action  by  central  irritation, 
induced  by  the  presence  of  a  tumor,  or  by  the  continued, 
or  strong  contraction  of  other  branches  of  the  3d  nerve ; 
(3)  reflex  when  due  to  neuralgia  of  the  5th  nerve,  or  to  in- 
testinal irritation  ;  (4)  paralytic  when  the  pupillary  fibres  in 
the  cervical  and  dorsal  plexus  of  the  sympathetic  are  com- 
pressed or  diseased  from  traumatism,  aneurism,  or  other 
causes.  Local  treatment  is  useless  when  the  myosis  is  the 
symptom  of  a  central  lesion. 

"ARGYLL-ROBERTSON  PUPIL"  is  that  condition  in  which 
the  pupil  contracts  under  the  impulse  supplied  by  the 
stimulus  of  the  3d  nerve  in  the  acts  of  convergence  and 
accommodation,  but  not  to  the  stimulus  of  light. 

HYPH.EMIA,  or  hemorrhage  into  the  anterior  chamber  from 
the  vessels  of  the  iris,  is  spontaneous  in  sudden  alteration  in 
the  tension  of  the  ball,  in  glaucoma,  and  in  menstrual  irregu- 
larities ;  and  traumatic,  in  wounds,  contusions  and  lacer- 
ations of  the  iris.  In  atrophied  eye-balls,  which  are  the  seats 
of  old  hemorrhages,  cholesterin  crystals  are  sometimes 
found  in  the  anterior  chamber.  Treatment  is  unnecessary. 

DETACHMENT  OF  THE  IRIS  from  the  ligamentum  pec- 
tinatum,  may  occur  as  the  result  of  a  severe  blow,  and 
is  always  attended  by  hyphaemia,  and  by  partial  and  tem- 
porary loss  of  vision.  After  the  blood  has  been  absorbed, 
the  eye  may  regain  normal  vision.  No  treatment  will 
restore  the  iris  to  its  former  position. 
14 


154  A    MANUAL   OF   CLINICAL    OPHTHALMOLOGY. 

TUMORS  OF  THE  IRIS. 

CYSTS. — One  or  more  cysts,  ranging  in  size  from  a  pin- 
head  to  a  pea,  with  solid  or  fluid  contents,  the  result  usu- 
ally of  traumatism,  may  form  on  any  part  of  the  surface  of 
the  iris,  and  are  attended  with  moderate  inflammatory 
symptoms.  They,  together  with  the  underlying  iris,  should 
be  excised  at  the  earliest  possible  moment. 

TUBERCLE  is  a  collection  of  small,  whitish  elevations  con- 
taining tuberculous  matter,  scattered  over  the  surface,  and 
coexist  with  similar  growths  in  the  choroid.  They  precede, 
or  are  developed,  in  a  small  proportion  of  cases,  during 
general  tuberculosis. 

GRANULOMA  is  a  small  benign  tumor,  resembling  in 
appearance  a  granulation  of  the  conjunctiva.  The  treat- 
ment is  by  excision  with  iridectomy. 

GUMMA  is  a  syphilitic  tumor,  springing  from  the  stroma 
at  the  pupillary  border,  or  near  the  periphery  of  the  iris,  and 
consists  of  a  mass  of  spindle-shaped  cells,  gummous  exuda- 
tion, and  newly-formed  connective  tissue,  brownish-yellow 
in  color,  round  in  outline,  vascular  at  its  base,  and  projecting 
as  far  forward,  in  some  instances,  as  the  posterior  surface  of 
the  cornea.  It  makes  its  appearance  at  the  end  of  the 
second  or  the  commencement  of  the  third  stage  of  constitu- 
tional syphilis,  and,  like  gumma  in  other  parts  of  the  body,  is 
amenable  to  mercury  and  potassium  iodide  administered  in 
large  doses. 

DISEASES  OF  THE  CILIARY  BODY. 
CYCLITIS,  or  inflammation  of  the  ciliary  body,  is  rarely  an 
independent  affection,  but  usually  associated  with  disease 
of  the  iris  or  choroid,  and  should  be  considered  as  a  com- 
plication, or  concurrent  symptom,  in  connection  with  inflam- 


DISEASES    OF   THE   CILIARY    BODY.  155 

matory  disease  of  these  tissues.  It  is,  therefore,  an  extension 
of  inflammation  of  the  iris,  or  choroid  to  the  ciliary  body, 
characterized  by  an  increased  sensibility  to  touch  in  the  cil- 
iary region,  and  by  the  presence  of  opacities  in  the  anterior 
portion  of  the  vitreous  humor. 

Treatment. — Locally,  atropine,  hot  water  applications,  and 
leeches  to  the  temple.  Internally,  mercury  and  the  iodides, 
or  jaborandi. 

SYMPATHETIC  OPHTHALMIA. — The  course  of  sympa- 
thetic inflammation  is  marked  by  two  distinct  and  separate 
degrees  of  advancement,  the  stage  of  irritation  and  the  stage 
of  inflammation,  which  must  be  unmistakably  recognized. 
The  first  stage,  always  the  precursor  of  the  second 
unless  promptly  discovered  and  checked  by  operation, 
is  declared  by  a  decrease  in  the  range  of  accommodation 
in  the  eye  not  primarily  affected,  by  photophobia,  lacry- 
mation,  slight  pericorneal  injection,  sluggishness  of  the  iris 
under  the  stimulus  of  light  and  of  accommodation,  and 
perhaps,  by  tenderness  upon  pressure  over  the  ciliary 
region.  Following,  these  symptoms,  is  the  inauguration  of 
the  second  stage  with  exudation  into  the  anterior  chamber 
and  pupillary  space,  vitreous  opacities,  pain,  moderate  swell- 
ing of  the  optic  nerve,  and  oedema  of  the  retina.  The  flame 
is  now  well  lighted  up  in  the  eye,  and,  with  the  super- 
vention of  hypopyon,  iritis,  occlusion  of  the  pupil,  opacity 
of  the  lens,  shrinking  of  the  vitreous,  and  retino-choroiditis, 
goes  on  to  panophthalmitis,  atrophy,  and  destruction  of 
the  ball. 

The  disease  is  transmitted  along  the  ciliary  nerves,  or 
the  lymphatic  sheath  of  the  optic  nerve,  or  both. 

It  may  be  caused  by  a  foreign  body,  hernia  of  the  iris, 
anterior  synechia,  dislocated  lens,  a  cysticercus,  trauma- 


156  A    MANUAL   OF   CLINICAL   OPHTHALMOLOGY. 

tism,  bony  formation  in  the  vitreous  chamber,  or  by  the 
irritation  of  an  artificial  eye. 

Treatment. — Enucleation  of  the  eye  inducing  irritation,  in 
first  stage  ;  local  remedies,  and  mercurialization  for  the 
irido-choroiditis,  in  second  stage,  with  enucleation  of  infect- 
ing eye,  if  it  is  hopelessly  blind. 

CHRONIC  CVCLITIS  is  the  term  given  to  a  chronic  inflam- 
mation involving  nearly  all  the  tissues  of  the  eye,  eventu- 
ating in  the  abolition  of  function,  and  in  atrophy  of  the  ball, 
f>/ithisis  bnlbi.  As  a  result  of  traumatism,  an  unsuccessful 
cataract  extraction,  for  example,  the  uveal  tract  becomes 
inflamed,  the  iris  totally  adherent  to  the  lens  capsule,  pupil 
occluded,  lens  capsule  and  lens  opaque  (if  not  previously 
extracted),  ciliary  body  destroyed  (atrophied),  vitreous 
opaque  and  shrunken,  retina  detached,  and  the  choroid  dis- 
organized. The  cornea,  which  may  or  may  not  be  opaque, 
is  lessened  in  its  diameters.  If  inflammation  should  sub- 
sequently attack  the  eye  thus  destroyed,  as  not  infrequently 
happens,  the  occurrence  of  a  sympathetic  inflammation  in 
the  sound  eye  is  to  be  apprehended,  and  guarded  against. 
After  the  lapse  of  years,  the  vitreous  body  of  an  eye  de- 
stroyed through  chronic  cyclitis,  is  replaced  by  a  button  of 
bone,  deposited  very  gradually  from  the  choroid,  which, 
acting  as  a  foreign  body,  irritates  the  ciliary  nerves  by  con- 
stant friction,  and  leads  to  sympathetic  involvement  of  the 
sound  eye.  An  atrophied  eyeball  is,  therefore,  a  constant 
menace  to  the  integrity  of  its  fellow,  and  the  only  conser- 
vative treatment  is  enucleation. 


DISEASES   OF    THE    CHOROID.  157 

DISEASES    OF    THE   CHOROID. 

CHOKOIDITIS. — In  inflammation  of  the  choroid,  its  stroma 
is  infiltrated  with  amorphous  masses  of  exudation  and  col- 
lections of  densely  packed  cellular  elements  at  the  periphery, 
pole,  or  in  the  neighborhood  of  the  optic  nerve,  varying  in 
size  from  a  minute  point  to  the  patches  of  the  diameter  of 
the  disc,  or  even  larger.  The  pigment  layer  of  the  retina  is 
always  disturbed.  The  pigment  cells  are  either  absorbed 
or  undergo  proliferation,  collecting  in  masses  at  the  circum- 
ference of  the  patch.  The  exudate  becomes  absorbed  in 
the  later  stages  of  the  disease,  its  site  being  marked  by  an 
absence  of  pigment  as  well  as  of  vessels,  and  the  overlying 
retina  is  partly  destroyed  through  cicatricial  contraction. 
The  patches  vary  in  shape,  but  are  either  round  or  oval 
as  a  rule.  The  vitreous  contains  opacities,  and  is  generally 
fluid.  In  purulent  choroiditis,  pus  cells  are  dispersed  every- 
where through  the  meshes  of  the  choroid  and  retina,  and 
may  completely  fill  the  vitreous  chamber. 

The  retina  and  choroid  are  so  intimately  associated  in 
structure  and  function,  that  chronic  disease  of  the  one 
must  involve  the  other.  The  names  given  to  the  various 
clinical  manifestations  of  choroidal  and  retinal  disease  de- 
pend on  the  membrane  in  which  it  originates,  but  in  every 
case  it  is  a  retino-cJwroiditis.  The  effect  on  vision  of  retino- 
choroiditis  will  depend  on  the  site  of  the  exudation,  whether 
central  (at  or  near  the  fovea)  or  peripheral,  and  on  the 
amount  of  retinal  tissue  destroyed.  It  is  much  less,  as 
a  rule,  than  the  ophthalmoscopic  appearance  would 
indicate. 

DISSEMINATED  CHOROIDITIS  (Fig.  69)  is  a  collection  of 
small,  roundish  aggregations  of  yellowish,  subsequently 
white,  exudation,  surrounded  by  deposits  of  pigment, 


158  A    MANUAJL  OF   CLINICAL   OPHTHALMOLOGY. 

scattered  at  first  irregularly  throughout  the  periphery,  and, 
finally,  in  the  neighborhood  of  the  disc  and  macula.  They 
rarely  increase  in  size. 

AREOLAR  CHOROIDITIS  (Fig.  70). — In  this  form  of  cho- 
roiditis  the  patches,  fewer  in  number  and  larger  in  size 
than  in  disseminated  choroiditis,  are  deposited  here  and 
there  throughout  the  fundus. 

CENTRAL  CHOROIDITIS  is  a  limitation  of  the  inflamma- 
tory and  atrophic  changes  to  the  macular  region. 

CENTRAL  SENILE  ATROPHY  is  characterized  by  absorp- 
tion of  the  choroidal  tissue  and  destruction  of  the  retina 
at  and  around  the  fovea,  preceded,  possibly,  by  apoplexy 
of  the  choroid. 

CENTRAL  GUTTATE  CHOROIDITIS  (Fig.  71)  is  the  term 
employed  to  designate  the  deposition,  immediately  behind 
the  retina,  of  from  six  to  twelve  minute  chalk-like  aggrega- 
tions involving  the  fovea,  or  adjacent  to  it,  and  associated 
with  partial  destruction  of  the  retina.  It  is  commonly 
found  in  old  persons. 

OPHTHALMOSCOPIC  APPEARANCES. — By  the  aid  of  the  oph- 
thalmoscope, the  observer  is  enabled  to  determine  variations 
from  the  normal  in  color,  together  with  the  size,  site,  shape, 
approximate  number  arid  character,  of  the  discolorations  de- 
scribed above.  In  the  earlier  stages  of  choroidal  disease, 
the  patches  present  a  yellowish  hue,  which  gradually 
assume,  as  the  ghoroid  is  absorbed,  the  bluish-white  color 
ofi»the  sclera,  and  are  distinctly  outlined  by  a  black  border 
of  pigment.  They  vary  in  size  and  number,  and  are  irregu- 
lar in  shape.  Occasionally  a  choroidal  vessel  is  found  run- 
ning across  the  patch.  Among  the  patches,  too,  are  often 
seen  sm?ll  black  pigment  spots,  irregular  in  outline,  which 
appear  to  be  situated  in  the  retina,  as  determined  by  their 
relation  to  the  retinal  vessels.  The  difference  of  level  be- 


DISEASES    OF   THE    CHOROID. 
FIG.  69. 


ATROPHY   AFTER   SYPHILITIC  CHOROIDITIS,  SHOWING  VARIOUS  DEGREES 

OF  WASTING. 

a.  Atrophy  of  pigment  epithelium,  b.  Atrophy  of  epithelium  and  chorio-capillaris ;  the 
large  vessels  exposed,  c.  Spots  of  complete  atrophy,  many  with  pigment  accumula- 
tion. 


FIG.  70. 


CENTRAL  CHOROIDITIS  (  Wecker  and  Jaeger]. 


l6o  A    MANUAL  OF   CLINICAL  OPHTHALMOLOGY. 

tween  the  centre  of  the  patch  and  the  adjoining  fundus  is 
always  difficult,  and  sometimes  impossible,  to  estimate ;  if, 
however,  the  choroidal  vessels  have  disappeared,  and  the 
retinal  vessels  pass  over  the  affected  spot,  it  is  safe  to 
assume  that  the  choroid  is  the  main  and  original  seat  of 
the  disease. 

In  disseminated  choroiditis  the  spots  are  nqmerous,  and 
average  about  half  the  size  of  the  disc.     They  are  found, 

FIG.  71. 


CENTRAL  GUTTATE  SENILE  CHOROIDITIS. 

in  the  earlier  stages  of  the  disease,  scattered  over  the  equa- 
torial zone.  In  areolar  choroiditis  the  patches  are  larger, 
several  times  the  diameter  of  the  disc,  but  fewer  in  num- 
ber, and  usually  involve  the  posterior  pole.  Round  masses 
of  pigment  are  spread,  in  its  earliest  stages,  through  the 
fundus,  but  these  undergo  gradual  absorption,  beginning  in 
the  centre  and  advancing  to  the  circumference,  leaving  a 
white  spot  traversed  by  retinal  vessels  and  outlined  by 


DISEASES    OF   THE   CHOROID.  l6l 

pigment.  The  pigment  line,  in  turn,  is  often  girdled  by  a 
zone  of  opaque  retina.  The  earliest  change  discernible  by 
the  ophthalmoscope  in  central  choroiditis,  is  a  collection  of 
pigment  spots  in  a  mass  of  exudation,  elevating  the  retina 
at  and  in  the  immediate  neighborhood  of  the  fovea.  As  the 
disease  advances  the  spots  become  confluent,  the  exudation 
shallower,  and  the  branches  of  the  small  retinal  vessels 
turning  toward  the  fovea  are  seen  to  bend  at  the  margin 
of  the  plaque.  Eventually  the  chorqid  atrophies,  and 
the  overlying  retina  is  destroyed,  presenting  the  general 
appearances  noticed  in  other  forms  of  choroiditis.  The 
whitish  patch  involving  the  foveal  region  in  central  senile 
atrophy,  is  preceded  by  no  ophthalmoscopic  evidence  of 
inflammation.  In  choroiditis  guttata,  the  ophthalmoscope 
reveals  a  collection,  surrounding  the  fovea  or  between  the 
fovea  and  disc,  of  pale  yellow  and  glistening  white  dots, 
which  have  no  clinical  significance. 

In  all  forms  of  acute  choroiditis,  vitreous  opacities  are 
discernible  by  the  ophthalmoscope. 

SYMPTOMS  IN  GENERAL. — The  main  symptom  is  an  im- 
pairment of  vision,  the  character  and  degree  of  which  will 
depend  on  the  site  of  lesion,  the  extent  of  retinal  implica- 
tion, and  vitreous  opacities.  The  visual  declination  is,  it 
may  be  remarked  here,  not  so  great  as  the  ophthalmo- 
scopic appearances  would  lead  one  to  suppose.  The  patient 
will  complain  of  a  grayish  or  blackish  defect  in  the  centre 
of  the  object  in  view  (positive  scotoma),  or,  later  on,  of  an 
utter  effacement  of  the  object  in  its  centre  (negative  scotoma), 
or  of  a  distortion  of  the  object  (metamorphopsia),  and  of 
sparks  or  flashes  of  light  or  color  when  the  lids  are  opened 
or  closed,  owing  to  an  irritation  of  the  retinal  elements 
(photopsia).  The  patient  will  complain,  too,  of  spots  or 


1 62  A    MANUAL   OF   CLINICAL   OPHTHALMOLOGY. 

clouds  which  float  before  the  sight,  especially  marked  in  a 
bright  light 

In  purulent  choroiditis,  the  pseudo-glionia  of  some  writers, 
vision  is  lost  in  a  few  hours  because  of  the  quick  destruc- 
tion of  the  choroid  and  retina.  Pus  can  easily  be  seen,  by 
oblique  illumination,  collected  in  the  vitreous  chamber.  The 
anterior  chamber  is  shallow,  iris  and  lens  adherent,  and 
both  pushed  forward  by  the  purulent  mass. 

The  causes  of  choroidal  disease  are  numerous.  Con- 
genital and  acquired  syphilis,  traumatism,  metastatic 
infarction  due  to  epidemic  and  sporadic  cerebro-spinal 
meningitis,  and  other  contagious  fevers,  pyaemia,  endocar- 
ditis, and  high  myopia,  may  be  mentioned. 

Treatment. — In  its  early  stages  or  manifestations,  the  dis- 
ease may  be  cured,  or  at  least  checked,  by  the  energetic 
employment  of  the  mercurials  and  iodides.  The  cause 
must  be  ascertained  and  treated  on  general  principles. 


PART  X. 

DISEASES   OF  THE  VITREOUS. 

HYALITIS.: — Inflammation  of  the  vitreous  is  not  an  inde- 
pendent affection,  but  a  development  of  cyclitis  or  choroid- 
itis.  It  is  characterized  by  a  change  of  consistency, 
opacities,  and  by  partial  disorganization  of  its  own  tissue. 
The  opacities  are  of  three  varieties,  namely,  clouds  of  fine 
dust,  significant  of  syphilitic  disease  of  the  choroid ; 
membranes,  following  hemorrhage,  retinal  detachment, 
and  syphilitic  chorio-retinitis ;  and  threads,  or  irregularly- 
shaped,  dense,  separate  flocculi,  seen  in  high  grades  of 
myopia,  and  in  the  various  forms  of  chronic  choroiditis. 
Purulent  infiltration  and  degeneration  of  the  vitreous  fre- 
quently follow  the  entrance  into  the  chamber  of  foreign 
bodies,  choroiditis  metastica,  entozoon,  etc.,  and  eventuate 
in  phthisis  bulbi. 

MUSCLE  VOLITANTES  are  minute  physiological  vitreous 
elements,  causing  a  subjective  sensation  of  shadows  floating 
before  the  eye,  not  revealed  by  the  ophthalmoscope,  and 
while  their  existence  is  annoying,  they  are  of  little  patho- 
logical importance.  The  causative  agency  is  supposed  to 
be  ametropia,  since  they  are  dissipated  by  its  correction. 

SYNCHISIS  is  the  name  given  to  a  fluid  condition  of  the 
vitreous. 

SYNCHISIS  SCINTILLANS  is  the  designation  given  to  an 
accumulation  of  cholesterine  and  other  crystals  in  the 

163 


164  A    MANUAL   OF   CLINICAL   OPHTHALMOLOGY. 

vitreous,  revealed  by  the  ophthalmoscope  as  glittering  or 
silver-like  reflections  which  move  in  all  directions. 

The  prognosis  of  vitreous  opacities  should  always  be  in- 
fluenced by  the  reflection  that  they  are,  in  fact,  the  floating 
wrecks  of  a  preceding  destructive  inflammation  of  the 
choroid  and  retina, — the  visible  marks  of  an  inflammatory 
storm  in  these  parts. 

Treatment  is  not  encouraging.  In  opacities  due  to 
syphilitic  disease,  some  improvement  may  be  expected  from 
mercury  and  the  iodides.  In  a  word,  the  underlying  cause 
must  be  discovered  and  combated.  The  syphilis  may  yield 
to  treatment,  the  hemorrhage  be  absorbed,  and  the  foreign 
body  removed  by  the  proper  treatment. 

PERSISTENT  HYALOID  ARTERY. — In  intra-uterine  life  the 
lens  is  supplied  with  blood  from  the  hyaloid  artery,  a 
straight  vessel  given  off  to  the  posterior  surface  of  the  lens 
from  one  of  the  branches  of  the  central  retinal  artery.  It 
persists,  as  a  fibrous  cord,  with  its  anterior  end  either 
attached  to  the  posterior  surface  of  the  lens  or  floating 
unattached  in  the  vitreous,  in  a  small  proportion  of  cases, 
and  can  easily  be  seen  with  the  ophthalmoscope. 

FOREIGN  BODIES,  such  as  metallic  chips,  splinters  of 
wood,  shot,  etc.,  are  sometimes  driven  with  great  force 
through  the  external  coats  of  the  eye,  and  find  lodgment 
in  the  vitreous  chamber.  It  is  a  serious  accident,  termi- 
nating in  the  partial  or  complete  destruction  of  the  ball  from 
supervening  purulent  inflammation,  and  is,  moreover,  a  pro- 
lific source  of  sympathetic  ophthalmia.  The  diagnosis  is 
determined  by  the  presence  of  a"  superficial  wound,  sudden 
loss  of  vision,  reduced  tension,  blood  in  the  anterior  and 
vitreous  chambers,  and,  in  some  instances,  by  the  ophthal- 
moscope and  magnetic  needle. 

A  foreign  body  in  the  vitreous  sometimes  becomes  en- 


DISEASES    OF   THE   VITREOUS.  165 

cysted,  and  remains  for  years  without  giving  rise  to  serious 
symptoms.  Its  removal,  by  means  of  a  magnet,  is  advis- 
able when  practicable.  If  vision  is  completely  and  perma- 
nently lost,  leaving  a  painful  ball,  enucleation  should  be 
promptly  performed. 


PART  XI. 

GLAUCOMA. 

Glaucoma  is  a  disease  characterized  by  abnormally  in- 
creased intra-ocular  pressure,  usually  and  arbitrarily 
described  under  two  main  divisions,  primary  and  secondary. 
The  primary  is  subdivided  into  non-inflammatory  or  simple, 
and  inflammatory. 

SIMPLE  GLAUCOMA  is  a  gradually  advancing  blindness 
with  attendant,  probably  consequential,  excavation  of  the 
optic  nerve — "  amaurosis  with  excavation."  Its  pathology 
is  not  understood.  The  symptoms  are  not  readily  suggest- 
ive of  the  disease.  The  patient  complains  of  gradually 
diminishing  vision,  and  nothing  more,  as  a  rule.  Even  the 
pressure  symptoms  are  negatively  conspicuous.  In  truth, 
the  symptoms  of  simple  glaucoma  are  so  little  characteristic, 
that  a  diagnosis  between  cataract,  atrophy  of  the  nerve 
from  other  causes,  and  simple  glaucoma  can  be  determined 
only  by  the  ophthalmoscope ;  and  even  with  this  instru- 
ment as  an  aid  to  diagnosis,  it  is  not  always  possible  to 
definitely  determine  whether  the  cupping  of  the  nerve  is  a 
precedent  and  independent,  or  a  subsequent  and  dependent, 
condition.  The  cup,  usually  involving  the  entire  disc,  is 
shallow,  surrounded  by  a  narrow  zone  of  atrophied  choroid, 
and  the  arteries  on  the  disc  pulsate  spontaneously,  or  can 
be  made  to  pulsate  by  pressure  of  the  fingers  on  the  globe. 
The  field  of  vision  is  limited  concentrically,  or  the  nasal 
field  contracted,  while  the  extreme  temporal  field,  with 

166 


GLAUCOMA.  167 

possibly  one  or  more  scotomata,  is  preserved  to  the  last. 
Both  eyes  are,  in  the  majority  of  cases,  affected,  although 
the  disease  is  further  advanced  in  one  than  in  the  other, 
when  the  patient  comes  under  observation.  If  the  patient 
seeks  advice  at  a  certain  stage  of  the  affection,  it  may  be 
found  that  one  disc  is  totally  and  the  other  only  partially 
cupped.  The  disease  runs  a  very  chronic  course,  several 
years  intervening  before  blindness  is  complete.  Com- 
plete restoration  of  vision  is  rarely  attained.  The  progress 
of  the  disease  may  be  controlled,  under  favorable  condi- 
tions, by  operation. 

Treatment. — Eserine  ;  iridectomy ;  sclerotomy. 

CHRONIC  INFLAMMATORY  GLAUCOMA. — In  reference  to 
the  pathology  of  chronic  inflammatory  glaucoma  (Figs. 
72  and  73),  it  may  be  stated  that  changes  in  the  periphery 
of  the  iris,  which  lead  to  partial  closure  or  obliteration  of 
the  spaces  of  Fontana,  thus  preventing  the  outflow  of  intra- 
ocular fluids,  are  common.  But  whether  these  changes  in 
the  iris  are  primary  and  causative,  or  secondary  and  inci- 
dental to  the  glaucomatous  process,  is  a  question  that  has 
never  been  definitely  determined.  The  immediate  effect  of 
such  occlusion  or  obliteration  of  the  spaces  of  Fontana  is  to 
add  to  the  amount  of  intra-ocular  fluid,  and  hence  to 
increase  intra-ocular  tension.  Other  pathological  pro- 
cesses, namely,  peripheral  adhesion  of  the  iris  to  the  cornea 
through  inflammatory  exudation,  vascular  engorgement  of 
the  iris  and  ciliary  body,  atrophy  of  the  ciliary  muscle,  oblit- 
eration of  the  choroidal  vessels  and  atrophy  of  its  tissue, 
closure  of  the  lymph  spaces,  sclerosis  and  degeneration  of 
the  retina  and  optic  nerve,  are  directly  due  and  traceable  to 
increased  tension.  This  form  of  glaucoma  is  characterized 
by  the  occurrence,  following  a  premonitory  stage  of  vary- 


1 68 


A    MANUAL   OF    CLINICAL   OPHTHALMOLOGY. 


ing  duration,  of   attacks  of  true  glaucoma,  lasting  from 
twelve  to  twenty-four  hours. 

The  symptoms  of  the  premonitory  stage  are:  (l)  early 
presbyopia,  or  a  recedence  of  the  near  point,  due  to  pres- 
sure on  the  ciliary  muscle,  the  patient  requiring  a  stronger 


FIG.  73. 


GLAUCOMATOUS  EXCAVATION. 
{Ophtkalmoscopic  view.} 


GLAUCOMATOUS  EXCAVATION 

OF  THE  OPTIC  NERVE. 

(Vertical  section.} 


plus  glass  for  reading  than  the  age  would  indicate,  and  there 
may  be  also  a  real  diminution  of  refraction  (acquired  Hy- 
permetropia) ;  (2)  a  colored  ring  is  seen  around  a  gas  flame, 
caused  by  slight  opacities  in  the  media  and  by  the  dilated 
pupil ;  (3)  periodic  obscuration  of  vision  and  ciliary  neural- 


GLAUCOMA.  169 

gia  due  to  temporarily  increased  pressure.  The  objec- . 
tive  signs  present  are  increased  tension,  as  determined 
by  palpation  over  the  closed  lid,  or  directly  on  the 
sclera  (normal  tension  is  expressed  by  the  letters  Tn.; 
slightly  increased  tension  by  Tn.  -{-  I ;  undoubtedly  hard  by 
Tn.  -f-  2  ;  stony  hard  by  Tn.  -f-  3  ;  when  slightly  less  than 
normal,  by  Tn.  —  I ;  undoubtedly  soft  by  Tn.  —  2,  very  soft 
by  Tn.  —  3) ;  pulsation  of  the  arteries  on  the  disc,  either 
spontaneous  or  easily  induced  by  pressure  on  the  globe. 
The  intra-ocular  pressure  is  so  high  that  the  blood  enters  the 
ball  only  with  the  systole  of  the  heart,  interrupting  the  con- 
tinuous flow  through  the  artery,  thus  producing  a  systolic 
pulsation.  This  sign  is  not  infrequently  found  in  aortic  dis- 
ease, and  in  exophthalmic  goitre,  and  is  occasionally  found 
in  persons  apparently  free  from  cardiac  disease.  Venous  pul- 
sation has  no  pathological  significance.  The  retinal  veins  are 
hyperaemic,  tortuous,  and  expanded  in  calibre.  The  pupil  is 
dilated  and  sluggish,  a  direct  consequence  of  pressure  on 
the  ciliary  nerves.  There  is,  lastly,  some  opacity  of  the 
aqueous  humor  from  the  exudations  of  venous  stasis. 

The  prodromic  stage  may  be  said  to  be  at  an  end,  and 
true  glaucoma  begun,  when,  following  one  of  these  periodic 
attacks,  the  symptoms  just  described  are  unusually  pro- 
nounced, with  marked  deterioration  of  vision.  Each  succes- 
sive attack  is  progressively  severe,  and  occurs  at  lessening 
intervals,  until  the  eye  presents  the  distressingly  character- 
istic appearances  of  glaucoma  with  vision  entirely  destroyed. 
The  ciliary  vessels  are  injected,  the  anterior  chamber  shal- 
low, the  pupil  widely  dilated  and  immobile,  the  iris  atro- 
phied, the  lens  partly  opaque  and  slightly  dislocated 
forward,  the  disc  surrounded  by  a  ring  of  atrophied  choroid, 
and  the  eye,  now  blind,  is  the  seat  of  periodic  attacks  of 
pain  of  the  most  excruciating  character. 
15 


I/O  A    MANUAL   OF   CLINICAL  OPHTHALMOLOGY. 

Treatment. — During  the  premonitory  stage,  an  attack 
may  be  warded  off  by  the  instillation  of  a  solution  of  eser- 
ine  sulphate  (gr.  ij-5j),  repeated  every  two  hours  until  the 
symptoms  are  relieved.  When  the  disease  is  unmistakably 
developed,  iridectomy  should  be  at  once  performed. 

ACUTE  INFLAMMATORY  GLAUCOMA. — A  sudden  outbreak 
of  this  disease,  preceded  in  some  cases  by  prodromic  symp- 
toms, is  announced  by  unmistakable  signs.  The  conjunc- 
tiva is  chemotic,  the  anterior  ciliary  and  pericorneal  vessels 
intensly  injected,  the  cornea  presents  a  steamy  appearance 
and  is  denuded  of  its  epithelium,  the  anterior  chamber  is 
shallow  and  the  aqueous  humor  turbid,  the  iris  widely 
dilated,  oval  and  unresponsive  to  light,  and  but  feebly,  if  at 
all,  contracted  by  eserine,  and  the  color  of  the  pupillary  space 
is  grayish-green  from  opacity  of  the  cornea  and  aqueous 
humor,  and  from  reflection  of  light  from  the  lens.  The  fundus 
is  invisible.  The  patient  complains  of  intense  ciliary  neural- 
gia, the  pain  radiating  over  the  forehead  and  down  the  side 
of  the  nose,  and  of  rapid  and  complete  loss  of  vision,  which 
is  due  to  paralysis  of  the  retina  and  optic  nerve  from  exces- 
sive pressure.  The  attack  lasts  several  days.  The  signs  of 
pressure  slowly  subside,  pain  is  diminished  and  finally  disap- 
pears and  vision  is,  in  part,  restored,  although  the  eye  never 
entirely  regains  its  lost  functions.  Or,  the  acute  may  gradu- 
ally pass  into  the  chronic  form  of  the  disease.  An  eye  once 
attacked  by  acute  glaucoma  is  predisposed  to  subsequent 
attacks.  The  optic  nerve  becomes  excavated  several  days  or 
weeks  after  the  acute  onset  has  subsided.  The  perform- 
ance of  iridectomy  should  immediately  follow  the  diagnosis. 

FULMINATING  GLAUCOMA  is  the  term  applied  to  those 
cases  in  which  the  above  conditions  are  most  pronounced, 
and  vision  is  lost  in  a  few  hours. 

Treatment. — Iridectomy. 


GLAUCOMA.  I/I 

SECONDARY  GLAUCOMA  is  a  result  of  certain  local,  chronic 
inflammatory  diseases  in  which  the  intra-ocular  pressure 
becomes  permanently  increased  with  excavation  of  the  optic 
papilla.  Among  the  causes  thus  operative,  may  be  men- 
tioned anterior  and  annular  synechiae,  traumatic  cataract, 
dislocation  of  the  lens,  and  intra-ocular  tumors.  The 
prodromal  stage  is  wanting.  The  symptoms  are  identical 
with  those  of  chronic  inflammatory  glaucoma.  Prognosis 
is  unfavorable. 

Treatment. — Iridectomy  or  sclerotomy. 

Glaucoma  may  be  complicated  with  other  diseases,  such 
as  cataract,  detachment  of  the  retina,  atrophy  of  the  optic 
nerve,  etc.  Its  etiology  is  obscure.  It  affects  persons  who 
have  passed  the  middle  of  adult  life,*  and  preeminently 
those  of  a  gouty  diathesis. 

GLAUCOMATOUS  DEGENERATION. — After  an  eye  has  been 
in  the  condition  of  absolute  glaucoma  for  a  varying  period 
of  time,  which  cannot  be  accurately  stated,  it  under- 
goes secondary  changes  of  a  degenerative  character.  Its 
volume  may  be  decreased  from  ulcerative  processes  in  the 
cornea,  through  which  the  cataractous  lens  and  part  of  the 
fluid  vitreous  are  expelled  by  hemorrhages  from  the  dis- 
eased vessels  of  the  retina  and  choroid,  phthisis  bulbi,  or 
the  weakened  sclera,  unable  to  resist  the  abnormal  intra- 
ocular pressure,  becomes  staphylomatous,  and  the  diame- 
ters of  the  ball  enlarged.  During  the  period  of  glau- 
comatous  degeneration,  the  globe  is,  ordinarily,  the  seat 
of  intense  pain.  The  ball  should  be  enucleated. 

*  Mr.  Priestly  Smith  has  advanced  the  theory,  based  on  numerous  carefully 
conducted  examinations,  that  idiopathic  glaucoma  is,  in  the  main,  dependent 
on  an  increase  in  size  of  the  crystalline  lens  which,  he  claims,  is  common  in 
advancing  life. 


PART  XII. 

NON-INFLAMMATORY  DISEASES  OF  THE 
RETINA. 

HYPER/EMIA  is  an  increase  in  length  and  width  of  the 
large  retinal  vessels,  recognized  by  their  lateral  and  vertical 
tortuosity,  dark  color,  pronounced  light  reflex,  which  ex- 
tends far  out  toward  the  periphery  of  the  fundus,  by  an 
increase  in  the  apparent  number  and  size  of  the  smaller  twigs, 
and  by  the  color  of  the  optic  disc,  which  presents  a  deep  red 
appearance  so  nearly  the  color  of  the  surrounding  fundus 
that  the  normal  contrast  in  color  between  the  two  parts 
is  almost  lost.  Pulsating  veins  on  the  disc  are  not  infre- 
quently found  in  the  absence  of  disease,  and  are  not  patho- 
logically significant,  when  moderate  and  confined  to  the 
superior  and  inferior  veins,  but  pulsation  of  the  smaller 
veins,  and  especially  when  it  is  noticeable  some  distance 
from  the  trunk,  must  be  accepted  as  an  evidence  of  disease. 

Hyperaemia  of  the  retina  and  nerve,  when  it  is  not  the 
initial  stage  of  an  acute  inflammatory  process,  is  an  indica- 
tion of  local  irritation  from  ametropic  strain,  an  associated 
symptom  of  disease  of  the  uveal  tract,  or  an  evidence  of 
central  congestion  or  inflammation.  The  normal  retinal 
variations  are  so  great,  that  the  diagnosis  is  difficult. 

The  cause  should  be  determined  and  treated  on  general 
principles. 

ANAEMIA  of  the  retina  is  a  symptom  of  constitutional 
dyscrasia.  The  calibre  of  the  arteries  is  decreased,  and 

172 


DISEASES   OF   THE    RETINA. 


173 


they  are  less  numerous,  relatively,  on  the  disc  than  in 
health.  The  veins  are  unaltered,  or  slightly  tortuous,  and 
the  disc  pale. 

EMBOLISM  OF  THE  CENTRAL  RETINAL  ARTERY  (Fig.  74) 
is  a  clot  or  embolus,  which  cuts  off  the  retinal  circulation, 
and  is  immediately  followed  by  complete  and  incurable 
blindness.  The  distal  branches  assume  a  thread-like 


FIG.  74. 


EMHOLISM  OF  THE  CENTRAL  ARTERY  OK  THE  RETINA. 


appearance,  and  have  no  light  reflex.  The  veins  are  thin, 
the  disc  white,  and  pulsation  in  the  arteries  or  veins  can- 
not be  induced  by  pressure  on  the  ball.  Degeneration  of  the 
retina  rapidly  follows.  It  becomes  opaque;  the  opacity  be- 
ing more  pronounced  in  the  region  of  the  fovea,  in  which 
situation  a  well-marked,  round,  red  spot  (the  choroid  thus 
showing  its  normal  color  through  the  thinnest  portion  of 
the  retina  by  contrast  with  the  surrounding  opacity)  is  dis- 


174  A    MANUAL   OF   CLINICAL   OPHTHALMOLOGY. 

tinctly  seen.  Atrophy  of  the  retina  and  nerve  follow. 
Embolus  of  a  branch  of  the  central  artery  of  the  retina  is 
occasionally  found,  and  the  part  of  the  retina  nourished 
by  the  affected  vessel,  becomes  opaque,  the  veins  dilated, 
and  localized  hemorrhages,  which  appear  as  dark  red 
blotches,  with  flame-like  marginal  serrations,  occur.  Vision 
is  lost  in  the  section  of  the  field  governed  by  the  diseased 
retina. 

Embolus  is  caused  by  hypertrophy  and  valvular  disease 
of  the  heart,  atheroma,  pregnancy,  and  Bright's  disease. 

Treatment  is  of  no  avail. 

The  pathological  changes  of  retinitis  are  modified  by  the 
cause,  nature  and  tissue  limitations  of  the  process.  The 
inflammation  may  be  limited  to  the  retina,  or  involve  the 
optic  nerve,  papilla  and  choroid. 

In  oedema,  the  fibre  and  nerve  layer  of  the  retina  is  infil- 
trated by  serum,  which  separates  its  elements  into  spaces 
of  varying  size.  The  fibres  are  compressed,  opaque,  gran- 
ular, and  swollen.  The  entire  retina  may  be  affected. 

In  hemorrhagic  retinitis,  the  blood  primarily  escapes  into 
the  nerve-fibre  layer  or  immediately  below  it,  and  thence  into 
the  other  layers,  destroying  the  elements  by  compression. 
The  interstitial  coagula  may  extend  forward  into  the  vit- 
reous. The  blood-cells  break  up  finally,  and  the  portion 
not  absorbed  is  changed  into  lymph  corpuscles,  which  form 
whitish  or  yellowish  plaques.  In  extensive  hemorrhage, 
the  retinal  pigment  is  disturbed  and  a  pigmented  cicatrix 
formed.  Small  hemorrhages  may  be,  and  frequently  are, 
entirely  absorbed. 

HEMORRHAGE  OF  THE  RETINA  is   a  single,  or   multiple 
effusion  of  blood.     It  occurs,  without  preceding  inflamma- 
tion, as  the  result  of  a  blow,  high  myopia,  choroidal  disc 
or  as  a  symptom  of  some  functional  or  organic  disturbance 


DISEASES    OF   THE   RETINA.  175 

in  other  situations  of  the  body.  The  exuded  blood  collects 
in  one  or  more  spaces,  which  are  separated,  one  from 
the  other,  by  compressed  retinal  tissue,  and  undergoes 
partial  or  complete  absorption.  The  unabsorbed  portion 
of  the  blood  is  formed  into  collections  of  lymph-cells,  with 
alterations  in  the  underlying  pigment.  Retinal  hemorrhage 
is  easily  recognized  by  the  ophthalmoscope  as  flame-shaped, 
or  round,  dark-red  spots  in  the  neighborhood  of  the  disc  or 
fovea.  The  presence  of  non-traumatic  hemorrhage  into  the 
retina,  is  indicative  of  some  grave  disorder  in  other  parts 
of  the  system — diabetes,  or  atheroma  of  the  vessels,  for 
instance. 

OPAQUE  NERVE  FIBRES  is  a  shiny,  white  and  irregu- 
larly band-shaped  opacity,  a  continuation  forward  into  the 
fibre  layer  of  the  retina,  of  the  white  substance  of  Schwann, 
which  normally  stops  at  the  scleral  opening.  It  is  phy- 
siological, and  its  only  effect  on  vision  is  to  increase  the 
size  of  the  blind  spot. 

INFLAMMATORY  DISEASES  OF  THE  RETINA. 
HEMORRHAGIC  RETINITIS. — In  this  affection,  the  most 
prominent  ophthalmoscopic  symptom  is  extravasations  of 
blood  in  the  retina.  The  hemorrhagic  areas  are  minute 
and  numerous,  scattered  here  and  there  throughout  the 
fundus,  and  are,  as  a  rule,  in  close  proximity  to  the  larger 
arteries.  Spots  of  hemorrhage  also  appear  on  and  in  the 
immediate  neighborhood  of  the  swollen  disc.  The  retina  is 
opaque  from  oedema,  the  veins  large,  dark  and  tortuous,  the 
arteries  are  conversely  small,  some  of  them  appearing  as 
white  lines  devoid  of  blood.  The  disc  is  hyperaemic,  its 
outlines  obscured  by  exudation,  and  small  parallel  fine 
stripes,  hypertrophied  nerve  fibres,  radiate  from  it  into  the 
retina.  Yellow,  or  whitish  round  patches  (old  hemorrhages, 


1/6  A    MANUAL   OF   CLINICAL   OPHTHALMOLOGY. 

fatty  degeneration,  or  choroidal  exudation)  are  seen  in 
the  retina.  The  vitreous  is  partly  opaque  from  hemorrhages 
into  its  substance  from  the  choroid  or  retina. 

The  retinitis  may  be  considered  either  as  the  cause  of  the 
extravasation,  as  in  neuro-retinitis  from  cerebral  tumor,  or 
as  a  result  of  it.  In  the  latter  case,  the  hemorrhagic  spots  arc- 
not  so  numerous,  and  are  limited,  moreover,  to  the  retinal 
section  in  which  an  infarction  or  embolus  has  occurred,  or 
exclusively  to  the  region  of  the  macula. 

The  effect  on  vision,  depends  largely  on  the  extent  and 
site  of  the  hemorrhage,  and  on  the  proportion  of  nerve  and 
retinal  tissue  destroyed.  Examination  will  reveal  one  or 
more  scotomata,  central  or  peripheral,  with  diminution  of 
central  vision  from  oedema  of  the  retina  and  vitreous  opa- 
cities. The  disease  may  involve  one  or  both  eyes. 

Treatment  must  be  determined  by  the  cause.  Rest, 
leeching,  and  counter-irritation  are  indicated  locally. 

ALBUMINURIC  RETINITIS  (Fig.  75). — The  retina  in  this 
disease,  is  the  seat  of  pathological  changes.  The  papilla 
is  oedematous  and  swollen,  the  surrounding  retina  oedema- 
tous,  and  slightly  detached.  The  rods  and  cones  arc 
partly  destroyed.  The  nerve- fib  re  layer  is  infiltrated  with 
exudation.  The  fibres  are  hypertrophied,  sclerosed,  or 
transformed  at  intervals  along  their  course  into  granules 
and  fat  cells,  especially  marked  in  the  region  of  the  macula. 
The  vascular  walls  are  thickened,  and  the  lumen  of  the  ves- 
sels contracted.  Hemorrhages  occur  in  the  fibre  and 
granular  layers. 

Ophthalmoscopic  examination  reveals  a  hyperaemic  and 
swollen  disc,  the  outlines  of  which  are  lost,  parallel  white 
lines  or  stripes  running  into  the  retina,  swollen  veins,  normal 
arteries,  small  hemorrhages  in  the  neighborhood  of  the  disc, 
round,  white,  small  isolated  patches  of  granular  and  fat  cells, 


DISEASES    OF   THE    RETINA. 


177 


and  a  stellate  series  of  bright,  glistening  stripes  of  hypertro- 
phied  and  infiltrated  fibres,  which  radiate  from  the  macula. 
From  these  appearances,  the  diagnosis  of  kidney  disease  is 
easily  made. 

The  disturbance  of  vision  is  not  so  great  as  the  appear- 
ances thus  revealed  might  lead  one  to  suppose.     The  acuity 

FIG.  75. 


RETINITIS  ALBUMINURICA. 


of  central  vision  is  moderately  reduced,  but  there  is  no  limi- 
tation of  the  field,  no  scotoma,  nor  loss  of  color  perception. 
The  retinal  changes  occur,  as  a  rule,  late  in  the  course  of 
the  disease,  are  chronic  in  character,  and  involve  both  eyes. 
They  vary  with   the  intensity  of  the  kidney  affection.      If 
the  nephritic  inflammation  is  relieved,  the  eye  lesions  may 
16 


1/8  A    MANUAL   OF   CLINICAL  OPHTHALMOLOGY. 

entirely  disappear.  Ordinarily,  however,  the  diagnosis  is 
grave. 

Treatment  is  general  and  symptomatic. 

Retinal  hemorrhages,  hemorrhagic  retinitis  with  plaques 
of  white  degeneration,  paleness  of  the  disc,  distended  and  tor- 
tuous veins,  and  vitreous  opacities,  are  frequently  observed 
as  localized  expressions,  in  many  of  the  severer  blood 
affections,  such  as  leucocythemia,  pernicious  anaemia,  and 
in  diabetes  insipidus  and  mellitus.  Treatment  should  be 
directed,  as  in  albuminuric  retinitis,  to  the  primary  dis- 
ease. To  promote  absorption  of  the  hemorrhage,  iodide  of 
potassium  in  small  doses  is  recommended. 

DIFFUSE  CHRONIC  RETINITIS  is  pathologically  character- 
ized by  an  infiltration  of  the  retina,  the  inner  layers  more 
especially,  with  lymph  cells,  numerous  along  the  vascular 
areas,  followed  by  the  growth  of  interstitial  connective  tis- 
sue. The  nerve  fibre  and  molecular  layers,  thickened  and 
permeated  in  spots  by  retinal  pigment,  finally  atrophy, 
destroying  in  part  the  rods  and  cones.  The  choroid,  in  the 
majority  of  cases,  participates  in  the  morbid  process  as  ;i 
disseminated  choroiditis,  and  the  optic  nerve  is  swollen 
from  infiltration  of  solid  and  fluid  exudation. 

By  the  ophthalmoscope  the  papilla  is  seen  to  be  hyper- 
aemic,  the  edge  of  the  disc  indistinct,  the  choroidal  rin^ 
veiled  by  oedema,  the  retina  around  the  disc  opaque,  the 
opacity  fading  peripherally  to  the  normal  reflex,  the  arteries 
reduced  in  calibre,  the  veins  distended,  and  all  vessels  more 
or  less  veiled  in  the  neighborhood  of  the  disc  by  the  retinal 
opacity,  which  is  more  marked  in  this  situation.  The 
fluid  vitreous  is  filled  with  fine,  dust-like  opacities,  which 
float  in  clouds,  or  appear  as  dense  and  large  membranes. 
Circular  patches  of  atrophied  choroid,  surrounded  by 
pigment,  are  frequently  found  near  the  periphery.  Corneal 


DISEASES    OF   THE    RETINA.  179 

opacities  and  the  marks  of  an  old  iritis,  are  sometimes 
observed. 

Symptoms. — Diminished  central  vision,  particularly  in 
dull  light,  floating  clouds  or  spots,  photopsia,  metamorphop- 
sia,  slight  limitation  of  the  field  peripherally,  deficient  color 
sense  in  the  late  stages,  and,  frequently,  scotomata.  Diffuse 
chronic  retinitis  may  be  either  monocular  or  binocular,  is 
chronic  in  its  course,  liable  to  relapses,  and  ends,  unless 
treated  energetically,  in  atrophy  of  the  optic  nerve  and 
retina. 

Tertiary  and  congenital  syphilis,  chronic  choroiditis, 
and  sympathetic  inflammation,  are  among  the  common 
causes  of  the  disease,  which  may,  however,  arise  idio- 
pathically. 

Treatment  consists  in  local  blood-letting,  counter-irrita- 
tion and  mercurial  inunctions,  carried  to  the  point  of  sali- 
vation, and  in  the  liberal  exhibition  of  the  iodides. 

RETINITIS  PIGMENTOSA  (Fig.  76)  is  chronic  in  its  mani- 
festations. Gradually  the  nervous  elements  of  the  optic 
nerve  and  retina  atrophy.  The  layers  of  the  retina,  which 
is  involved  in  its  entire  thickness,  are  infiltrated  with  pig- 
ment, which  collects  in  great  abundance  in  the  fibre  layer, 
and  especially  along  the  blood-vessels  at  their  bifurca- 
tions. Cystic  degeneration  occurs  in  places  with  complete 
destruction  of  the  rods  and  cones.  The  vascular  walls, 
arterial  and  venous,  are  thickened  and  their  lumen  so  dimin- 
ished that  they  appear  peripherally  as  white  lines  or  fibrous 
cords.  The  optic  nerve  is  finally  completely  atrophied. 

Symptoms. — Central  and  peripheric  vision'slowly  declines 
until  the  perception  of  light  is  lost,  the  field  contracting 
concentrically,  central  vision  being  retained  to  the  last. 
Night  blindness  (hemeralopia)  is  one  of  the  earliest  symp- 
toms of  which  the  patient  complains.  Pigment  spots  of 


I  SO  A    MANUAL   OF   CLINICAL   OPHTHALMOLOGY. 

curious  shape,  not  unlike  bone  corpuscles,  more  numerous 
peripherally  than  around  the  disc,  are  revealed  by  the  oph- 
thalmoscope. These  spots  are  greatest  in  number  at  the 
bifurcation  of  the  larger  vessels.  The  disc  is  white,  the 
arteries  and  veins  reduced  in  number,  size  and  calibre. 

FIG.  76. 


RETINITIS  PIGMENTOSA. 


and  are  accompanied  by  white  lines.    The  light  column  is 
very  fine,  or  altogether  lost. 

The  disease,  usually  developed  in  young  persons,  is 
hereditary,  a  frequent  taint  in  the  offsprings  of  consanguin- 
eous marriage,  continues  through  a  long  course  of  years, 
and  affects  both  eyes. 


DISEASES    OF   THE   RETINA..  l8l 

Treatment  is  of  very  little  value  ;  electricity  and  "strych- 
nine may,  however,  retard  its  course,  and  should  be  em- 
ployed. 

DETACHMENT  OF  THE  RETINA  (Fig.  77)  is  a  separation 
from  the  choroid  of  all  except  its  pigment  layer.  The 
detachment  may  be  confined  to  a  small  area,  or  include 
the  entire  retina  from  the  optic  nerve  to  the  ora  serrata.  It  is 
caused  by  the  sudden  or  gradual  discharge  of  fluid  from 
the  choroidal  vessels,  the  exudation  of  solid  inflammatory 
new  formations,  the  development  of  choroidal  tumors,  or 

FIG.  77. 


OPHTHALMOSCOPIC  APPEARANCE  OF  DETACHED  RETINA  (ERECT  IMAGE). 
<*  After  Wecker  and  Jaeger. 

by  contraction  of  the  connective  tissue  elements  of  the 
retina.  The  detached  retina  floating  forward  in  the  vitreous 
is  not  at  first  appreciably  changed  from  the  normal,  but  it 
eventually  becomes  degenerated,  thickened  and  opaque, 
from  a  diffuse  hyperplasia  and  consequent  atrophy  of  its 
nervous  elements.  The  subretinal  fluid  is  thin,  yellowish  in 
color,  and  contains  fat,  lymph,  blood-cells,  and  cholesterin. 
The  fluid  may  be  altogether  sanguineous.  The  vitreous  is 
opaque,  partly  fluid,  and  partly  transformed  into  connective 
tissue.  Tension  is  diminished. 

Symptoms. — There  is  a  sudden  loss  of  a  part  of  the  visual 


1 82  A    MANUAL   OF   CLINICAL   OPHTHALMOLOGY. 

field,  the  position  and  extent  of  which  corresponds  to  the 
position  and  extent  of  the  retinal  detachment.  CentraJ 
vision  is  deteriorated,  objects  distorted  or  only  seen  in 
part,  and  black  opacities  float  in  the  visual  field.  As  the 
fluid  changes  its  position,  gradually  subsiding  to  the  most 
dependent  portion  of  the  fundus,  the  blindness  correspond- 
ingly alters.  A  portion  of  the  field  is  usually  retained  for 
a  long  period  of  time,  but  is  eventually,  and  gradually, 
lost  through  cataractous  formation,  or  other  degenerative 
changes. 

The  ophthalmoscope  shows  a  blue-white  or  gray  reflex, 
much  nearer  the  observer's  eye  than  the  bright  red  reflex  of 
the  healthy  fundus  surrounding  it.  The  detached  retina, 
which  is  seen  most  clearly  with  a  strong  convex  glass  (20  u), 
floats  in  wavy  undulations,  and,  adhering  to  its  uneven  sur- 
face dark  lines,  vessels  from  which  the  central  bright  line  of 
reflex  has  disappeared,  are  seen.  Floating  vitreous  opacities 
are  invariably  present. 

Detachment  of  the  retina  is  caused  by  traumatism,  high 
myopia  with  posterior  staphyloma,  tumors,  hemorrhage, 
cysticercus,  and,  perhaps,  by  uncorrected  presbyopia.  The 
prognosis  is  unfavorable,  although  in  a  small  proportion 
of  cases,  the  retina  returns  to  its  normal  position  under 
treatment. 

Treatment. — The  patient  should  be  kept  in  recumbent 
position,  a  pressure  bandage  applied  over  the  eyes,  and 
hypodermic  injections  of  pilocarpine,  gr.  ^,  repeated  often 
enough  to  insure  profuse  perspiration,  are  administered. 
\Yhcn  the  detachment  is  not  caused  by  tumor,  high 
myopia,  or  other  evident  organic  change,  an  operation  by 
which  the  subretinal  fluid  is  allowed  to  drain  off",  is  advis- 
able. 

ACUTE  CENTRAL  RETINITIS,  the  result  of  exposure  to 


DISEASES    OF    THE    RETINA.  183 

direct  sunlight,  or  to  the  reflection  of  the  sun  on  snow  or 
water,  is  an  active  inflammation  of  the  foveal  region,  char- 
acterized by  metamorphopsia,  and  central  scotoma  for  white 
and  colors.  The  ophthalmoscope  shows  one  or  more  white 
spots  at  the  fovea,  circumscribed  by  a  zone  of  redness, 
which  gradually  shades  off  into  the  normal  color  of  the 
fundus.  The  severity  of  the  lesion  will  depend  upon  the 
length  of  time  the  eye  has  been  exposed  to  the  light. 
Complete  recovery  is  unusual,  but  amelioration  of  the 
disease  follows  active  treatment  by  strychnia,  electricity, 
local  bleeding  during  the  congestive  stage,  and  protection 
from  light. 

HYPER/ESTHESIA  of  the  retina  is  a  condition  sometimes 
found  in  anaemic,  hysterical  women,  and  in  hypochondriacal 
men,  and  gives  rise  to  concentric,  or  irregular  limitation 
of  the  visual  field,  and  to  deterioration  of  central  vision. 
Lacrymation,  photophobia,  and  blepharospasm  are  accom- 
panying symptoms.  The  ophthalmoscope  shows  no  evi- 
dence of  disease.  Remedies  should  be  addressed  to  the 
cause,  the  eyes  put  at  rest,  protected  from  light,  and  the 
system  built  up  by  tonics. 

ANAESTHESIA  of  the  retina  is  a  rare,  functional  conse- 
quence of  latent  muscular  insufficiency  with  co-existing 
ametropia.  The  acuity  of  vision,  and  the  visual  field,  may 
be  at  first  normal,  but  invariably  deteriorate  during  exam- 
ination. The  patient  suffers  from  accommodative  and  muscu- 
lar asthenopia.  The  treatment  is  to  correct  the  error  of 
refraction  by  lenses,  and  the  muscular  anomaly  by  tenoto- 
mies. 

GLIOMA  OF  THE  RETINA  is  a  cancerous  growth,  composed 
of  softened  nerve  tissue  infiltrated  with  small  round  cells, 
which  spring  from  the  retina.  It  is  of  rapid  development, 


184  A    MANUAL  OF   CLINICAL  OPHTHALMOLOGY. 

invading  the  optic  nerve,  surrounding  parts  in  the  orbit 
and  skull,  and  terminates  fatally  in  a  few  months. 

Treatment. — Extirpation  of  the  eye-ball.  The  disease 
shows  a  singular  tendency  to  reappear  in  the  second  eye,  or 
in  the  brain. 

CONTINUED  EXPOSURE  to  bright  light,  or  to  its  reflection 
from  water  or  snow,  or  to  dazzling  flashes  of  lightning,  may 
lead  to  structural  changes  in  the  retina  near  the  fovea. 
They  are  revealed  by  the  ophthalmoscope  as  a  closely 
united  collection  of  pale-yellow  and  small  round  spots. 
Patients  suffering  from  this  affection,  complain  of  metamor- 
phopsia,  and  of  diminished  central  vision  or  of  negative 
scotoma.  It  is  in  some  cases  modified  by  treatment,  but 
usually  leaves  the  vision  permanently  crippled,  the  result 
of  destructive  changes  of  the  retina  at  the  fovea. 

Treatment  consists  in  rest,  and  in  protection  of  the  eyes 
from  light,  in  small  doses  of  potassium  iodide  and  mercury, 
and,  locally,  in  blood-letting  and  counter-irritation. 


PART  XIII. 
DISEASES  OF  THE  OPTIC   NERVE. 

The  physiological  variations  of  the  optic  nerve  as  seen 
by  the  ophthalmoscope  are  numerous,  and  by  this  means 
alone  one  is  often  unable  to  differentiate  between  them  and 
pathological  conditions.  The  disc  in  health  varies  in 
color ;  it  may  be  white  with  few  vessels,  or  so  red,  from  the 
presence  of  fine  vessels,  that  it  differs  very  little  from  the 
normal  choroidal  reflex ;  it  may  show  black  points  of  pig- 
ment, or  be  partly  or  wholly  surrounded  by  a  well-marked 
pigmented  ring  of  considerable  breadth ;  its  surface  may 
be  plane,  or  it  may  present  a  small  excavation  in  its  centre, 
or  nearly  the  entire  disc  may  be  physiologically  cupped,  and 
clearly  show,  at  its  bottom,  the  mottled  connective  tissue 
web  of  the  lamina  cribrosa.  Venous  pulsation  may  be 
present  or  absent.  The  size  and  divisions  of  the  arteries 
and  veins  in  health  are  not  invariable.  In  many  cases,  all 
areas  of  the  visual  field  for  white  and  colors,  and  for  sco- 
tomata,  must  be  determined  by  the  perimeter,  and  the 
acuity  of  vision  ascertained,  to  confirm  the  previous  diag- 
nosis by  the  ophthalmoscope. 

OPTIC  NEURITIS  (Fig.  78). — This  affection  is  character- 
ized by  hyperaemia  of  the  disc,  which  is  heightened  in  color 
from  the  presence  of  numerous  small  vessels,  exception- 
ally seen  in  the  normal  eye,  and  by  an  obliterative  exuda- 
tion of  inflammatory  products  into  its  excavation.  The  clear 
outline  of  the  disc,  thus  swollen  by  serous  and  solid  exuda- 

185 


1 86 


A    MANUAL   OF   CLINICAL   OPHTHALMOLOGY. 


tion  is  lost,  and  imperceptibly  fades  into  the  retina.  The 
veins  are  distended  and  pulsate,  the  arteries  either  normal  or 
reduced  in  size,  while  both  arteries  and  veins  are,  in  part, 
hidden  by  inflammatory  exudates.  The  retina,  in  immediate 
proximity  to  the  nerve,  is  streaked,  thickened,  and  slightly 
opaque.  In  mild  cases  of  optic  neuritis,  those  usually  classi- 
fied as  hyperaemia,  the  changes  just  cited  are  so  slight  that 

Fin.   78. 


it  is  extremely  difficult  to  arrive  at  a  correct  diagnosis  ;  on 
the  other  hand,  they  may  be  so  considerable,  as  in  choked 
disc,  that  even  the  site  of  the  nerve  can  be  only  negatively 
determined  by  the  blood-vessels.  In  the  latter  case,  .small 
hemorrhages  on  or  near  the  disc  are  common. 

PAPILLITIS  is  an  inflammation  limited  to  the  intraocular 
end  of  the  optic  nerve.     The  signs  manifest  by  the  ophthal- 


DISEASES    OF   THE    OPTIC    NERVE.  l8/ 

moscope,  correspond  to  those  described  in  optic  neuritis, 
and  affect  the  disc  and  retina  immediately  around  it. 

NEURO-RETINITIS  involves  the  retina,  as  well  as  the  optic 
nerve,  as  in  albuminuric  retinitis,  and  is  characterized  by 
hemorrhages,  patches  of  fatty  degeneration,  hypertrophy  of 
its  nervous  elements,  and  deposition  of  pigment. 

Symptoms. — Gradual  failure  of  central  vision.  The  vis- 
ual field  is  contracted  peripherally,  or  in  sectors  for  white 
and  colors,  and  these  may  involve  one- half  the  field  (hemi- 
anopsia).  Central  color  scotoma  is  an  occasional  symptom. 
There  is  an  absence  of  pain. 

In  optic  neuritis  there  is  an  exudation  of  serous  and 
plastic  material  in  and  about  the  papilla,  perivasculitis, 
formation  of  new  blood-vessels,  swelling  of  the  nerve 
fibres,  and  cedema  of  the  optic  sheath  just  behind  the 
sclera.  At  a  later  stage  of  the  morbid  process,  the  inter- 
cellular infiltration  is  transformed  into  connective  tissue 
which,  by  pressure,  cuts  off  the  supply  of  blood  to  the  nerve 
fibres,  causing  them  to  atrophy,  or  to  undergo  fatty  degen- 
eration. 

Among  the  numerous  causes  of  optic  neuritis  may  be 
mentioned  brain  and  orbital  tumors,  injuries  to  the  skull, 
simple  and  tubercular  meningitis,  erysipelas,  periostitis, 
anaemia,  diabetes,  Bright's  disease,  diphtheria,  scarlet  and 
typhoid  fever,  measles,  etc. 

Optic  neuritis  due  to  incurable  constitutional  or  orbital 
disease,  ends  in  total  atrophy  of  the  nerve  fibres,  in  the 
course  of  a  few  months  or  years.  When  due  to  syphilitic 
tumors,  or  other  curable  affections,  local  or  systemic,  the 
optic  neuritis  slowly  subsides  under  treatment,  and  vision 
may  be  completely  restored.  More  frequently,  however, 
the  disease  is  only  checked,  the  vision  being  permanently 
impaired. 


1 88  A    MANUAL  OF   CLINICAL   OPHTHALMOLOGY. 

Treatment  should  be  actively  and  persistently  carried  on. 
The  underlying  cause,  whatever  it  may  be,  should  be  ascer- 
tained and  the  remedies  best  suited  to  its  relief  or  cure, 
administered.  Potassium  iodide  and  mercury,  local  and 
general  bloodletting,  and,  in  acute  cases,  profuse  diaphoresis 
should,  as  a  rule,  be  employed  independently  of  the  cause. 

RETRO-BULBAR  OPTIC  NEURITIS  is  manifested  in  two 
forms,  acute  and  chronic.  Acute  retro-bulbar  optic  neuritis 
is  caused  by  exposure  to  cold,  sudden  cessation  of  the  men- 
strual flux,  and  other  causes  which  lead  to  a  sudden  serous 
exudation  into  the  vaginal  sheath  of  the  optic  nerve.  Total 
blindness  follows  in  a  few  days,  the  result  of  pressure  on  the 
blood-vessels  and  consequent  functional  inactivity  of  the 
nerve  fibres.  The  ophthalmoscope  reveals  a  papillitis  of 
moderate  severity.  The  disease,  if  seen  in  time,  yields  to 
energetic  and  well-directed  medication,  that  is  to  say,  to 
general  blood-letting,  salivation,  and  active  diaphoresis. 

Chronic  retro-bulbar  optic  neuritis,  is  an  interstitial 
inflammation  affecting,  primarily,  the  axial  fibres,  and, 
secondarily,  all  fibres  of  the  optic  nerve.  There  is  an  hyper- 
trophy of  the  connective  tissue  fibres,  followed  by  atrophy 
of  the  nerve.  The  ophthalmoscope  shows  a  dull,  slightly 
hyperaemic  and  foggy  papilla,  the  outline  of  which  is  in 
places  obscured.  The  veins  are  enlarged  and  the  arteries 
diminished  in  size. 

The  symptoms  are  slowly  diminishing  central  vision  ;  cen- 
tral color  perception  and,  later,  perception  for  white,  is  lost. 
The  patient's  single  complaint  is  loss  of  vision  ;  no  pain  or 
headache  is  experienced.  Its  most  common  cause,  is  the 
excessive  use  of  tobacco  and  alcohol,  one  or  both.  Other 
toxic  agents,  such  as  quinine,  lead,  and  syphilis,  cause 
this  form  of  the  disease. 

Treatment. — In  tobacco  and  alcohol  amblyopia  the  causa- 


DISEASES    OF   THE   OPTIC    NERVE. 


189 


tive  agents  must  be  abandoned  in  toto,  and  strychnine 
hypodermatically  administered  in  increasing  doses.  This 
treatment  will  in  most  cases  greatly  relieve,  or  altogether 
cure,  if  the  disease  has  not  advanced  to  atrophy.  Elec- 
tricity is  also  indicated  in  these  cases.  If  syphilis  is  the 
cause,  iodide  of  potassium  and  mercury  are  the  most  effect- 
ive remedies. 

ATROPHY  OF  THE  OPTIC  NERVE  (Fig  79). — Atrophy  of 

FIG.  79. 


ATROPHIC  EXCAVATION. 

the  optic  nerve  fibres  is  the  result  of  an  increase  in  the  in- 
terstitial connective  tissue  in  the  intra-ocular  extremity 
alone,  or  in  the  nerve  stem  from  the  chiasm  to  the  ball.  It 
is  primary  when  the  result  of  a  neuritis,  and  secondary  when 
the  deep  origin  of  the  nerve  is  destroyed,  or  when  the  retina 
is  the  site  of  the  original  lesion.  Atrophy  of  the  intra-ocular 
extremity  of  the  nerve  is  the  result  of  disease  of  the  nerve, 
papilla,  or  of  the  retina. 


I9O  A    MANUAL   OF    CLINICAL   OPHTHALMOLOGY. 

Causes. —  I.  Mechanical  pressure  from  tumors,  orbital 
cellulitis,  meningitis,  inflammatory  exudates,  traumatism, 
and  in  hydrocephalus.  2.  Embolus  in  the  central  retinal 
artery,  which  cuts  off  the  blood  supply,  and  in  this  way 
starves  the  nerve.  3.  Traumatic  or  surgical  section  of  the 
nerve.  4.  Disease  of  nerve  at  its  periphery,  the  retina,  or 
at  its  origin  in  the  optic  thalami  and  neighboring  basal 
ganglia.  5.  Gray  degeneration  of  the  optic  nerve,  the  final 
stage  of  neuritis  medullaris,  in  which  the  fibres  undergo 
softening  and  destruction  in  one  or  more  bundles.  6.  Sim- 
ple atrophy  of  the  nerve  trunk,  and  its  intra-ocular  end 
as  a  part  of  a  similar  process  in  the  brain  and  spinal  cord. 
This  form  is  frequently  associated  with  tabes  dorsalis  and 
cerebral  sclerosis. 

OPHTHALMOSCOPIC  APPEARANCES  vary  with  the  cause  of 
the  atrophy.  The  disc,  in  atrophy  following  papillitis,  is  in- 
creased in  size,  and  the  lamina  cribrosa  and  its  outline  are 
more  orl*ss  obliterated  by  exudation  in  its  tissue  as  well  as 
in  the  surrounding  retina.  The  arterial  walls  are  thickened 
and  their  lumen  lessened ;  the  veins  may  be  distended  and 
tortuous,  normal,  or  reduced  in  size,  and  marks  of  old  hem- 
orrhages, and  of  pigment  changes,  are  discernible  around 
the  disc.  The  disc,  following  interstitial  and  medullary 
neuritis,  is  discolored,  its  edges  and  centre  appear  veiled, 
and  the  arteries  and  veins,  particularly  the  former,  are 
small.  There  are  no  evidences  of  gross  lesions.  The 
disc  in  simple  or  progressive  atrophy  of  the  optic  nerve, 
is  of  a  dead  or  bluish-white,  sharply  outlined  against  the 
red  reflex  from  the  choroid.  The  lamina  cribrosa  is 
distinctly  visible,  the  nerve  cupped,  arteries  reduced  to 
white  threads  without  any  appearance  of  capillary  dis- 
tribution, the  veins  more  numerous  and  distinct  than 
the  arteries,  but  not  so  large  or  numerous  as  in  health. 


DISEASES    OF   THE    OPTIC    NERVE.  19! 

The  symptoms  are  gradual  diminution  in  the  acuity  of 
vision,  concentric  limitation  of  the  visual  field  for  white  and 
colors,  loss  of  sectors  of  the  field,  central  white  and  color 
scotoma,  and  hemianopsia.  Both  eyes  are  usually  involved, 
the  disease  advancing  equally  in  the  two  eyes,  or  more  rap- 
idly in  one  than  in  the  other. 

Treatment. — Iodide  of  potassium,  oxide  of  silver,  bichlo- 
ride of  mercury  and  electricity. 

TOBACCO  AND  ALCOHOL  AMBLYOPIA. — In  this  disease, 
which  occurs  so  frequently  and  is  so  amenable  to  treatment 
that  it  would  seem  to  demand  separate  mention,  the  con- 
nective tissue  binding  together  the  bundles  of  nerve  fibres 
becomes  hypertrophied,  and  the  nerve  fibres  themselves  un- 
dergo fatty  degeneration  late  in  the  course  of  the  disease, 
either  from  pressure,  or  from  the  direct  action  of  the  toxic 
agents.  The  structural  changes  in  the  optic  nerve  trunk  in 
case  of  simple  tobacco  amblyopia  are  not  easily  determined, 
because  persons  addicted  to  the  excessive  use  of  tobacco 
are,  in  a  very  great  majority  of  cases,  also  intemperate  in  the 
use  of  alcohol.  The  symptoms  and  ophthalmoscopic  appear- 
ances are,  however,  identical,  whether  the  cause  be  single  or 
dual.  These  changes  manifest  themselves  in  a  slow  deteriora- 
tion of  vision  with  central  color  scotoma,  the  peripheric  field 
of  vision  for  white  and  colors  remaining  unchanged  until 
late  in  the  progress  of  the  disease,  or  until  atrophic  changes 
are  well  marked  in  the  optic  nerve.  The  disc  is  either 
normal  or  slightly  hyperaemic,  and  its  outline  indistinct, 
at  least  in  part.  Later  in  the  course  of  the  disease,  the  disc 
presents  the  aspect  of  atrophy  which  follows  a  retro-bulbar 
neuritis,  so  that  it  is  discolored  and  comparatively  free  from 
vascularity. 

Unless  the  disease  has  progressed  to  atrophy  of  the  optic 
nerve  when  seen,  the  prognosis  is  good,  provided  the 


IQ2  A    MANUAL   OF    CLINICAL   OPHTHALMOLOGY. 

patient  can  abstain  altogether  from  the  use  of  tobacco  and 
alcohol.  Total  abstinence  from  the  use  of  alcohol  and 
tobacco  is  a  prerequisite  to  treatment,  which  consists, 
medicinally,  in  the  use  of  strychnine.  This  agent  should 
be  gradually  increased  until  maximum  doses,  the  fifth  of  a 
grain  three  times  daily,  are  reached.  Local  extraction  of 
blood  is  valuable  in  patients  who  are  not  anaemic.  Men 
are  more  frequently  affected  than  women,  and  both  eyes 
are  usually,  and  equally,  affected. 

HEMIANOPSIA  is  the  condition  in  which  one-half  of  the 
field  of  vision  is  lost.  It  is  bilateral  when  the  temporal 
half  of  one  and  the  nasal  half  of  the  other  eye  is  lost;  bi- 
tcinporal  when  the  temporal,  binasal  when  the  nasal  halves 
of  the  field  are  lost,  and  vertical  when  the  dividing  line  is 
horizontal  and  the  upper  or  lower  field  is  wanting.  The 
dividing  line,  vertical  or  horizontal,  rarely  passes  through 
the  point  of  fixation,  but  makes  a  small  curve  around  it, 
thus  showing  that  the  fovea  is  functionating.  Other  sec- 
tions, corresponding  in  each  eye,  may  be  obliterated.  The 
ophthalmoscope  reveals  nothing  abnormal,  excepting 
atrophy  of  the  optic  nerve  in  the  late  stages  of  the  disease. 

Hemian  )psia  is  caused  by  pressure  (tumor)  upon  half  the 
chiasm,  optic  tract,  or  deep  origin  of  the  nerve,  or  destruc- 
tion of  these  parts  from  other  organic  changes. 


PART  XIV. 
DISEASES  OF  THE  ORBITAL  CAVITY. 

PERIOSTITIS. — The  periosteal  lining  of  the  bony  walls  of 
the  orbital  cavity  is  sometimes  the  seat  of  inflammation  of  a 
chronic  character,  usually  limited  to  a  small  area.  The 
inflammatory  process  may,  however,  be  so  extensive  as  to 
involve  the  periosteum  lining  the  frontal  sinuses  and  the 
antrum  of  Highmore,  and  so  protracted  as  to  lead  to  ex- 
tensive necrosis  of  the  underlying  bones.  It  is  usually 
found  as  a  local  indication  of  syphilitic,  or  tuberculous 
disease.  The  local,  as  well  as  the  constitutional,  treatment 
is  the  same  as  for  periostitis  in  other  situations.  The  affec- 
tion rarely  involves  the  eyeball. 

PHLEGMON  OR  ABSCESS. — From  injury,  thrombosis,  ery- 
sipelas, etc.,  the  supporting  fat  and  loose  connective  tissue 
of  the  orbital  cavity  may  become  acutely  inflamed.  It  is  a 
purulent  inflammation,  characterized  by  marked  oedema 
and  increased  tension  of  the  conjunctiva  and  lids,  which  are 
distended  forward,  and  by  fixation  of  the  eyeball  in  a 
straight  or  deviating  position,  and  consequent  double 
vision.  It  is  an  acutely  painful  affection,  and  should  be 
relieved  by  free  incisions,  repeated  if  necessary,  drainage, 
and  by  antiseptic  dressings. 

TUMORS  OF  THE  ORBIT. — Cystic  tumors,  degeneration 
of  the  lacrymal  gland,  and  various  other  forms  of  benign 
and  malignant  growths,  are  not  uncommonly  met  with 
in  this  situation.  They  are  easy  of  diagnosis.  The  treat- 
ment is  by  removal. 

i7  193 


194  A    MANUAL   OF   CLINICAL   OPHTHALMOLOGY. 

EXOPHTHALMUS  is  a  bulging  forward  of  one  or  both  eye- 
balls. The  protrusion  of  one  eye  is  likely  to  be  the  result 
of  local  cause  (abscess,  injury,  aneurism,  etc.),  and  should 
be  treated  accordingly.  Protrusion  of  both  eyeballs  is,  on 
the  other  hand,  likely  to  be  the  result  of  a  remote  or  sys- 
temic cause,  such  as  hypertrophy  of  the  thyroid  gland,  or 
of  the  heart,  and,  under  these  conditions,  local  treatment  is 
of  no  avail. 

ENOPHTHALMUS  is  a  sinking  backward,  or  retraction  in 
the  orbital  cavity,  of  one  or  both  eyeballs.  In  senile 
enophthalmus,  which  is  due  to  the  gradual  absorption  of 
the  orbital  fat  in  old  persons,  both  eyes  are  affected  to  the 
same  degree.  When  one  eye  is  retracted  from  trauma- 
tism,  involving  a  fracture  of  the  walls  of  the  orbit,  the  result- 
ing inflammation  is  severe,  an  abscess  forms,  the  eyeball 
becomes  immovable,  and  atrophy!  of  the  optic  nerve  is 
the  ultimate  consequence. 


PART    XV. 
OPERATIONS. 

Such  portions  of  the  surgeon's  person  as  are  likely  to 
come  in  contact  with  the  patient,  as  well  as  the  instruments 
and  parts  to  be  operated  on,  should  be  free  from  infection. 
To  this  end,  the  operator's  hands  should  be  thoroughly 
scrubbed  with  soap  and  hot  water,  and  then  bathed  in  a 
1-5000  solution  of  the  bichloride  of  mercury.  Great  care 
must  be  exercised,  too,  to  render  aseptic  the  conjunctival 
sac,  the  under  surface  of  the  lids,  eyelashes  and  neigh- 
boring parts  of  the  patient's  face.  The  instruments  should 
be  disinfected  by  a  1—5000  solution  of  the  bichloride  of 
mercury,  or,  better  still,  by  a  saturated  solution  of  boric 
acid.  In  the  minor  operations,  as  for  squint,  pterygium, 
etc.,  these  prophylactic  measures  against  micro-organisms, 
may  be  considered  as  complete  when  the  operator's  hands 
and  instruments,  and  the  patient's  eye,  have  been  suitably 
cleansed.  Any  coincident  disease  of  the  eye  of  an  inflam- 
matory character  should  receive  the  necessary  attention, 
and  the  general  system  put  in  the  best  possible  condition, 
before  the  eye  is  invaded  by  the  surgeon's  knife  in  the 
graver  operations. 

The  eye  is  sufficiently  anaesthetized  by  four  or  five 
instillations,  at  intervals  of  five  minutes,  of  a  four  per 
cent,  solution  of  the  hydrochlorate  of  cocaine,  to  render 
all  operations,  except  enucleation,  painless.  For  plastic 

195 


196 


A    MANUAL   OF   CLINICAL   OPHTHALMOLOGY. 


operations  on  the  lids,  and  for  enucleation,  ether  should 
be  employed. 

CATARACT  EXTRACTION  WITH  IRIDECTOMY. — The  patient 


FIG.  80. 


LID  SPECULUM. 


is  placed  in  a  recumbent  position,  face  up,  and  the  eye  to  be 
operated  on  suitably  illuminated.  The  speculum  (Fig.  80) 
is  then  inserted  or  the  upper  lid  elevated  by  an  assistant,  the 


FIG.  81. 


FIXATION  FORCEPS. 


conjunctiva  of  the  ball  grasped  a  few  mm.  below  the  ex- 
tremity of  the  vertical  meridian  of  the  cornea,  and  gently 
but  firmly  held  by  fixation  forceps  (Fig.  81).  I.  A  cut  is 


FIG.  82. 


rafWAli  Co.  PH/LA. 


GRAEFE  CATARACT  KNIFE. 


made  through  the  cornea  with  a  Graefe  knife  (Fig.  82),  which 
is  entered  at  the  corneal  margin  just  above  its  horizontal 
diameter,  and  a  counter-puncture  made  exactly  opposite  by 
passing  the  knife  through  the  anterior  chamber  in  front  of  the 


OPERATIONS. 


197 


pupil.  By  a  sawing  movement  of  the  knife  with  its  cutting 
edge  upward,  the  corneo-scleral  border  is  divided  in  its  up- 
per two-fifths.  When  the  cut  is  finished,  the  fixation  forceps 
should  be  removed,  at  least  temporarily.  2.  A  portion  of 
the  iris,  is  removed  (iridectomy).  When  the  patient  is 
tractable,  the  iridectomy  should  be  made  without  fixation. 


FIG.  8- 


£A  YARNALL  CO.  PHILA 

IRIS  FORCEPS. 


The  patient  is  directed  to  look  downward  and  to  keep  the 
eye  perfectly  stiH.  The  iris  forceps  (Fig.  83)  are  intro- 
duced, closed,  through  the  centre  of  the  incision  previously 
made,  and  then  opened  in  order  to  grasp  a  portion  of  the 
iris,  near  its  pupillary  border,  which  is  slowly  withdrawn 
and  cut  off  at  its  periphery.  To  excise  a  large  piece,  as  in 

FIG.  84. 


IRIDECTOMY  SCISSORS. 

the  operation  for  glaucoma,  the  blades  of  the  iris  scissors 
should  be  held  at  right  angles  to  the  vertical  meridian  of 
the  cornea  and  more  than  one  clip  made,  but  in  the  operation 
for  cataract,  they  should  be  held  in  the  plane  of  the  vertical 
meridian,  as  only  a  small  section  of  the  iris  is  to  be  re- 
moved. 3.  The  anterior  capsule  of  the  lens  is  lacerated 


198 


A    MANUAL   OF    CLINICAL   OPHTHALMOLOGY. 


(capsulotomy).  A  cystotome  (Fig.  85)  is  introduced 
through  the  incision  as  far  as  the  lower  pupillary  margin 
with  its  cutting  point  directed  upward ;  one  quarter  revo- 

FIG.  85. 


FA.  YARNALL  CO.  PHILA. 


CYSTOTOME. 


lution  of  the  handle  is  then  made,  turning  the  point  back- 
ward, and  the  capsule  lacerated  vertically  and  horizontally. 
Another  quarter  revolution  of  the  handle  is  made,  and  the 


FIG.  86. 


EXPULSION  OF  THE  CATARACT. 


instrument  withdrawn  with  its  point  downward.  The  quar- 
ter revolutions  prevent  entanglement  of  the  instrument  in 
the  iris  and  cornea  on  entering  and  withdrawing  it.  4.  The 

FIG.  87. 


GRAEFE  CATARACT  SPOON  AND  CYSTOTOME. 

lens  (Fig.  86)  is  extruded  through  the  lacerated  capsule, 
artificial  pupil  and  corneal  cut,  by  gentle  and  sustained 
pressure  with  the  Graefe  spoon  (Fig.  87),  or  with  the 


OPERATIONS.  199 

finger,  on  the  inferior  portion  of  the  cornea  and  adjoining 
sclera,  assisted  by  counter-pressure  on  the  sclera  above 
the  cut.  5.  The  anterior  chamber  is  freed  from  blood,  and 
remaining  cortical  matter,  by  massage  with  the  spoon,  or  by 
gentle  injection  of  warm  distilled  water,  or,  better,  by  a 
solution  of  boric  acid,  gr.  v-Sj.  This  may  be  done  by 
means  of  an  ordinary  glass  dropper,  or  by  a  syringe 
specially  devised  for  the  purpose. 

A  small  pad  of  absorbent  cotton  anointed  with  vaseline, 
is  applied  over  the  closed  lids  of  both  eyes,  taking  care 
that  the  lashes  of  the  lower  lids  are  not  inverted,  and  held 
in  position  by  a  roll  of  flannel  bandage,  or,  preferably,  by 
a  piece  of  loose  worsted  knitted  for  the  purpose.  This 
dressing  should  remain  undisturbed  for  twenty-four  hours. 
At  the  expiration  of  that  time,  it  should  be  removed,  the 
eye  bathed  with  a  1-5000  solution  of  the  bichloride  of 
mercury,  or  with  a  saturated  solution  of  boric  acid,  and 
the  lower  lid  everted  to  permit  the  escape  of  tears  which 
may  have  collected.  The  eyes  are  again  dressed,  as  on 
the  preceding  day,  and  the  dressing  allowed  to  remain  for 
another  period  of  twenty-four  hours,  when  the  treatment  is 
repeated.  On  the  third  day  after  the  operation,  the  eye 
not  operated  on  may  be  left  unbandaged.  On  the  fifth  day, 
the  cut  may  be  inspected.  Up  to  the  fifth  day,  the  patient 
should  remain  in  bed,  resting  on  the  back  as  much  as  pos- 
sible. This  plan  of  treatment  should  be  closely  followed 
in  cases  that  run  a  normal  course.  If,  however,  severe 
pain  in  the  eye,  or  in  the  adjoining  parts,  develops,  indicat- 
ing iritis,  or  if  a  discharge  of  mucus  or  pus  is  noticed  on  the 
cotton  when  the  dressing  is  changed,  the  eye  must  be  ex- 
amined, and  appropriate  remedies  applied,  such  as  atropine 
instillations,  the  constant  application  of  a  saturated  solution 
of  boric  acid  by  means  of  absorbent  cotton,  and  leeches 


2OO  A    MANUAL   OF   CLINICAL   OPHTHALMOLOGY. 

applied  to  the  temple,  together  with  the  internal  adminis- 
tration of  potassium  iodide  and  mercury. 

In  this  operation,  certain  complications  are  likely  to  arise. 
First,  the  corneal  cut  may  not  be  sufficiently  large  to  admit 
of  the  easy  escape  of  the  lens ;  second,  if  there  is  prolapse 
of  the  iris  in  the  corners  of  the  wound,  it  must  be  replaced 
by  gentle  manipulation ;  third,  if  the  view  of  the  pupil  is 

FIG.  88. 


WIRE  LOOP. 

obstructed  by  a  collection  of  blood  in  the  anterior  chamber, 
it  should  be  expelled  through  the  open  wound  by  gentle 
and  repeated  upward  pressure  on  the  cornea  with  the 
spoon ;  fourth,  if  the  capsulotomy  is  too  small  to  admit  of 
the  passage  of  the  lens,  the  cystotome  should  be  reintro- 
duced  and  a  more  complete  division  of  the  capsule  made ; 
fifth,  if  a  bead  of  vitreous  presents  at  the  corneal  incision 

FIG.  89. 


LENS  EXTRACTOR. 

before  the  extraction  of  the  lens,  the  speculum  must  be 
withdrawn,  and  the  lens  removed  by  means  of  the  loop  or 
extractor  (Figs.  88  and  89). 

CATARACT  EXTRACTION  WITHOUT  IRIDECTOMY. — A  Graefe 
knife  is  used,  and  the  incision  includes  five-twelfths  of  the 
corneo-scleral  margin.  The  cut  is  made  through  the  cornea 
at  its  junction  with  the  sclera,  and  a  conjunctival  flap  avoided. 


OPERATIONS. 


2O  I 


An  extensive  division  of  the  lens  capsule  is  next  made  with 
a  Knapp  knife,  especially  designed  for  that  purpose,  which 
is  passed  under  the  iris  vertically  and  horizontally,  and  after 
division  of  the  capsule  slow,  steady,  and  continuous  pressure 
with  the  spoon  on  the  lowest  part  of  the  cornea  expels  the 
lens.  If  the  iris  prolapses,  it  must  be  replaced.  Eserine, 
gr.  j— 5J,  is  dropped  into  the  eye,  which  is  otherwise  treated 
as  in  the  preceding  modified  Graefe  operation,  before  it  is 


bandaged. 


FIG.  90. 


DlSCISSION. 


This  operation  is  both  difficult  and  dangerous.  The 
advantages  claimed  for  it  are  the  avordance  of  iritis,  which 
sometimes  follows  iridectomy,  the  round  pupil,  and  better 
vision.  The  dangers  to  be  considered  are  a  prolapse  of  the 
iris,  and  a  difficult  technique,  especially  in  the  performance 
of  the  capsulotomy. 

SOFT  CATARACT. — Discission  (Fig.  90)  is  the  generally 
accepted  operation  for  soft  cataract.  A  stop  needle  (Fig. 
18 


202 


A    MANUAL   OF    CLINICAL   OPHTHALMOLOGY. 


91)  is  passed  through  the  anaesthetized  cornea  into  the 
dilated  pupil,  the  capsule  freely  divided  and  the  lens  broken 
up  by  gentle  movements  of  the  needle  point  in  its  substance. 
The  moderate  reaction  which  follows  this  operation  is 
controlled  by  frequent  instillations  of  atropine,  gr.  viij-5J. 
If  the  reaction  is  severe,  the  lens  greatly  swollen  and  the  iris 

FIG.  91. 


SOFT  CATARACT  NEEDLE. 

bellied  forward  with  large  sections  of  the  lens  floating  in 
the  anterior  chamber,  an  incision  with  the  Graefe  or  iri- 
dectomy  knife  should  be  made  through  the  cornea,  and  the 
offending  masses  gently  pressed  out  (Fig.  92). 

IRIDECTOMY  is  performed  (Fig.  93)  in  glaucoma  to  lessen 
tension  and  to  establish  drainage  from  the  eye,  in  cataract 

FIG.  92. 


extraction,  lamellar  cataract,  in  the  removal  of  foreign  bodies 
from  the  anterior  chamber,  in  complete  annular  synechia::, 
and  for  optical  purposes.  The  eye  to  be  operated  on,  is  held 
as  in  the  operation  for  cataract  extraction,  and  an  incision 
made  with  the  lance  knife  (Fig.  93)  in  the  corneo-scleral 
border.  The  point  of  the  knife  is  passed  into  the  anterior 


OPERATIONS. 


203 


chamber,  in  front  of  and  parallel  with  the  plane  of  the  iris,  to 
the  necessary  depth.  In  withdrawing  the  knife,  its  handle  is 
tilted  backward  to  prevent  too  rapid  escape  of  the  aqueous 

FIG.  93. 


LINEAR  INCISION  AT  THE  SUPERIOR  MARGIN  OF  THE  CORNEA. 


FIG.  94. 


C.A.  YARN  ALL  CO.  PHILft. 


IRIDECTOMY  KNIFE. 


humor  and  prolapse  of  the  iris.  The  next  step,  without 
fixation  when  possible,  is  to  introduce  the  forceps  and  grasp 
the  iris,  which  is  then  withdrawn  and  excised  in  the  manner 


2O4  A    MANUAL   OF    CLINICAL   OPHTHALMOLOGY. 

already  described  in  the  operation  for  cataract.  Finally, 
the  angles  of  the  pupil  should  be  replaced,  and  the  margins 
of  the  wound  carefully  approximated.  The  eye  should  be 
dressed  as  described  in  the  operation  for  cataract  extrac- 
tion. At  the  expiration  of  twenty-four  hours  the  wound 

FIG.  95. 


ARTIFICIAL  PUPIL  AS  SEEN  IN  ANTERIOR  CHAMBER  AFTER  IRIDECTOMY. 

will  have  healed  with  re-establishment  of  the  anterior  cham- 
ber. The  bandage  may  be  discarded  in  three  days  and  a 
shade  substituted. 

IRIDOTOMY  or  IRITOMY  is  necessary  when  the  pupil,  as  a 
result  of  traumatism  or  cataract  extraction,  is  occluded  by 

FIG.  96. 

IRIDOTOMY  KNIFE. 

thickened  and  opaque  capsule  with  inflammatory  exuda- 
tions from  the  iris.  A  needle-knife  (Fig.  96)  with  double 
cutting  edge,  so  constructed  that  its  shank  completely  fills 
the  corneal  wound,  thus  preventing  the  escape  of  the  aque- 
ous, is  thrust  through  the  cornea  midway  between  its  centre 


OPERATIONS.  2O5 

and  periphery  and  into  the  occluding  membrane,  which 
is  divided  at  right  angles  to  the  line  of  greatest  tension. 
Scissors  (Fig.  97)  devised  by  De  Wecker  are  sometimes  suc- 
cessfully used  in  this  operation.  With  the  lance  knife,  a  small 
wound  is  made  between  the  centre  and  circumference  of  the 
cornea,  the  blade  is  then  slowly  withdrawn  half  way,  allowing 
the  aqueous,  which  carries  the  iris  forward  with  it,  to  partly 

FIG.  97. 


DE  WECKER'S  IRITOMY  SCISSORS. 

escape.  The  knife  is  then  thrust  through  the  iris  and  with- 
drawn. De  Wecker's  scissors  are  entered  closed,  opened  in 
the  anterior  chamber,  and  one  blade  passed  through  the  cut 
in  the  iris.  Both  blades  are  made  to  meet  through  the  iris, 
thus  elongating  the  incision  made  by  the  knife. 

PARACENTESIS  CORNEA  consists  in  perforating  the  cornea 
with  a  small,  double-edge  knife  (Fig.  98).     The  object  of 


FIG.  98. 

A.YARNflU  CO.  PH. 


PARACENTESIS  KNIFE. 

the  operation  is  to  reduce  intra-ocular  pressure  by  empty- 
ing the  anterior  chamber. 

S.EMISCH  INCISION  is  sometimes  resorted  to  for  the  pur- 
pose of  obviating  the  worst  effects  of  corneal  abscess.  The 
clear  cornea  immediately  surrounding  the  abscess  is  pene- 
trated by  a  Graefe  knife,  which  is  passed  through  the 


206 


A    MANUAL   OF    CLINICAL   OPHTHALMOLOGY. 


anterior  chamber  to  a  corresponding  point  in  the  clear 
cornea  on  the  distal  side  of  the  abscess,  dividing  it  in  its 
long  diameter.  This  procedure  drains  the  abscess  and 
union  is  promoted  by  the  expulsion  of  the  pus. 

CONICAL  CORNEA. — The  operation  for  this  condition,  con- 
sists in  excision  of  the  cone,  wholly  or  in  part,  by  a  Graefe 
knife,  and  bringing  the  divided  edges  together  by  sutures. 
Exceedingly  fine  needles  armed  by  a  single  strand  of  silk  are 

FIG.  99. 


NEEDLES  IN  POSITION. 


necessarily  used  in  thus  suturing  the  edges  of  the  wound. 
The  resulting  cicatrix  is,  perhaps,  less  detrimental  to  vision 
than  the  previously  existing  cone. 

STAPHYLOMA  OF  CORNEA  AND  SCLERA  (Figs.  99,  100, 
101). — Critchett's  operation  is  to  be  preferred  toenucleation 
in  children,  as  the  parts  of  the  ball  remaining  in  the  orbit 
will  prevent  unsymmetrical  development  of  the  bones  of  the 


OPERATIONS. 


207 


FIG.  100. 


EXCISION  OF  THE  STAPHYLOMA. 


FIG.  10 1. 


APPEARANCE  OF  THE  STUMP  AFTER  EXCISION  OF  THE  STAPHYLOMA. 


2O8  A    MANUAL   OF   CLINICAL   OPHTHALMOLOGY. 

face,  the  invariable  result  of  enucleation  in  children.  The 
operation  is  simple  and  effective.  Four  threaded  needles 
are  inserted  equi-distant  and  parallel  with  each  other 
through  the  base  of  the  staphyloma,  the  diseased  tissues 
are  then  removed  with  a  knife  or  scissors,  the  needles  drawn 
through,  and  each  thread  tied. 

CORNEAL  TATTOOING,  which  has  for  its  object  the  substi- 
tution of  a  black  and  invisible  for  a  white  and  disfiguring 
opacity  of  the  cornea,  is  effected  by  several  fine  steel  points 
or -needles  firmly  fastened  in  a  handle  (Fig.  102).  The 
points  are  dipped  in  a  solution  of  india  ink,  and  the  corneal 

FIG.  1 02. 


opacity  gently  punctured.  If  the  opacity  is  large,  several 
sittings  are  necessary  in  order  to  avoid  the  dangerous  reac- 
tion of  a  prolonged,  or  too  extensive  operation. 


FOREIGN    BODIES. 

A.  In  Conjunctiva. — To  inspect  the  lower  cul-de-sac,  the 
patient  is  directed  to  look  upward  while  the  lower  lid  is 
drawn  down  and  away  from  the  ball.   The  upper  cul-de-sac 
is  revealed  by  inverting   the  upper  lid,   and    having   the 
patient   look    downward.     A   foreign  body  when  seen   in 
either  of  these  situations,  is  easily  removed   by   a  small 
spud,  or  by  a  pledget  of  cotton  wound   on  the  end  of  a 
match  stick. 

B.  ///    Cornea. — Before    attempting    to    remove   foreign 
bodies  in  this  situation,  anaesthesia  of  the  part  should  be 
induced  by  a  single  instillation  of  a  four  per  cent,  solution 


OPERATIONS.  2O9 

of  cocaine.     The  body  is  then  lifted  or  removed  from  its 
position  by  a  spud  (Fig.  103),  or  other  suitable  instrument. 

C.  In  Anterior  Chamber. — If  the  body  is  iron  or  steel,  its 
removal  may  be  accomplished,  through  a  proper  opening 
in  the  cornea,  by  means  of  a  magnet.     In  the  absence  of  a 
magnet,  or  when  it  is   ineffective,  that  part  of  the  iris  on 
which  the  foreign  body  rests  should  be   drawn  out  and 
cut  off.     It  is  a  dangerous  and  often  impracticable  proceed- 
ing to  attempt  the  extraction  of  a  body  thus  placed,  without 
simultaneously  performing  an  iridectomy. 

D.  In   Lens. — The  presence   of  a   foreign  body   in  the 
lens,  such  as  a  fragment  of   metal  may  be   early  recog- 
nized with  the  ophthalmoscope  or  oblique  illumination,  by 
its    lustre.      If  it  has  passed  through   the   lens,   its  path 

FIG.  103. 


will  be  marked  by  a  streak  of  gray  opacity.  In  either 
case  a  cataract  develops  which  must  be,  when  sufficiently 
advanced,  extracted.  That  procedure  should  be  selected 
which,  in  case  the  lens  contains  the  body,  insures  its  extrac- 
tion, since  enucleation  will,  in  most  cases,  be  necessary 
eventually,  if  the  foreign  body  is  dislodged  into  the  vitreous 
chamber. 

E.  In  Vitreous  Chamber. — Extraction  of  the  body  by 
the  magnet  should  be  attempted.  Enucleation  of  the  ball,  in 
order  to  prevent  sympathetic  involvement  of  the  unaffected 
eye  is,  however,  usually  necessary. 

TENOTOMY  (Figs.  104  and  105).  The  conjunctiva  and 
capsule  of  Tenon  are  grasped  by  forceps  over  the  insertion 
of  the  tendon,  and  divided  at  right  angles  to  the  line  of  its 


2IO  A    MANUAL   OF   CLINICAL   OPHTHALMOLOGY. 


FIG.  104. 


INCISION  OF  THE  CONJUNCTIVA. 


FIG.  105. 


SECTION  OF  THE  TENDINOUS  INSERTION. 


FIG.  1 06. 


STRABISMUS  HOOK. 


OPERATIONS. 


211 


attachment.  A  tenotomy  hook  (Fig.  106)  is  passed  under  the 
tendon,  which  is  elevated  from  the  surrounding  parts,  and 
drawn  into  view.  The  tendinous  expansion  of  the  muscle 
at  its  attachment  to  the  sclera,  thus  brought  into  view, 
is  divided  by  several  clips  with  blunt-pointed  scissors  (Fig. 
107). 

GRADED  or  PARTIAL  TENOTOMY  consists  in  making  an 
incision,  not  exceeding  2  mm.,  through  the  conjunctiva 
and  capsule  of  Tenon,  as  described  in  the  foregoing  opera- 

FIG.  107. 


CONJUNCTIVAL   SCISSORS. 


tion  for  tenotomy,  and  passing  a  small  hook  (Stephen's) 
under  the  tendon,  which  is  carefully  separated  from  the 
sclera  in  its  central  attachment.  The  extent  to  which  the 
tendinous  division  of  the  muscle  is  carried  is  proportionate 
to  the  effect  desired.  In  practice,  it  will  be  found  that  no 
lessening  of  the  muscular  power,  as  determined  by  prisms, 
is  obtained  until  the  tendon  is  nearly,  if  not  completely, 
divided.  In  this  operation,  therefore,  the  cut  through  the 
conjunctiva  and  capsule  is  smaller  and  the  spreading,  lateral 
fibres  of  the  tendon  are  not  divided. 


212  A    MANUAL   OF    CLINICAL   OPHTHALMOLOGY. 

ADVANCEMENT  OF  A  TENDON. — The  enveloping  tissues, 
conjunctiva  and  capsule  of  Tenon,  are  dissected  until  the 
muscle  and  tendon  to  be  operated  on  are  brought  clearly 
into  view,  and  a  needle  armed  with  silk,  not  too  fine,  is 
passed  through  the  muscle  at  right  angles  to  its  course,  and 
carried  first  through  the  conjunctiva  above  and  then  below, 
the  cornea.  The  muscle  is  next  divided  in  front  of  the 
suture,  and  the  thread  drawn  firmly  and  tied.  The  effect 
of  the  operation  will  be  increased  by  excising  a  small  portion 
of  the  conjunctiva  and  capsule,  between  the  insertion  of  the 
tendon  and  the  cornea.  The  surgeon  should  be  careful  to 
pass  the  needle  through  the  capsule  as  well  as  conjunctiva, 
otherwise  the  thread  will  in  a  few  hours  cut  its  way  out, 
and  thus  aggravate  the  symptoms  the  operation  is  designed 
to  relieve.  The  sutures  should  be  removed  on  the  fourth 
or  fifth  day. 

Tenotomies  and  partial  tenotomies  are,  of  course,  to  be 
performed  upon  any  of  the  recti  muscles  that  may  be  at  fault. 

PTERYGIUM. — The  old  and  unsatisfactory  operation  of 
abscission  has  been  abandoned  in  favor  of  transplantation, 
a  simple  and  more  effective  method  of  treatment.  The  edges 
of  the  pterygium  are  grasped,  brought  together  and  the 
whole  mass  elevated  by  fixation  forceps.  A  strabismus 
hook  is  passed  under  the  pterygium  at  the  site  of  fixation 
by  rupturing  the  two  lateral  folds  of  adherent  conjunctiva, 
and  its  apex  detached  from  the  cornea  by  a  sudden  move- 
ment or  jerk  of  the  hook  in  the  direction  of  the  cornea. 
(No  operation  is  advisable  until  the  growth  has  invaded  the 
cornea.)  The  detached  apex  is  transfixed  by  a  thread 
armed  at  both  ends  with  a  needle,  and  the  two  needles  are 
carried  a  considerable  distance  under  the  conjunctiva  to  a 
point  obliquely  above  or  below  the  base  of  the  growth,  and 
passed  out  a  few  mm.  from  each  other.  The  threads 


OPERATIONS.  213 

are  made  taut,  drawing  the  apex  of  the  pterygium  up- 
ward or  downward  under  the  conjunctiva,  and  tied.  The 
pterygium  is  in  this  way  transplanted  and  allowed  to 
grow  without  subsequent  disturbance  to  vision,  or  other 
annoyance  to  the  patient.  The  traumatic  ulcer  of  the 
cornea,  made  by  tearing  off  the  hypertrophied  growth, 
heals  rapidly,  leaving  as  a  rule  a  nearly  invisible  opacity, 
which  may  be  disregarded.  The  thread  is  removed  on  the 
fifth  day. 

ENUCLEATION. — The  patient  is  placed  in  recumbent  posi- 
tion, anaesthetized  and  the  parts  thoroughly  disinfected.  The 
globe  is  exposed  as  much  as  possible  by  the  introduction 
of  a  speculum,  the  arms  of  which  are  held  widely  sepa- 
rated. The  surgeon  grasps  the  conjunctiva  adjacent  to  the 
inner  extremity  of  the  horizontal  diameter  of  the  cornea, 
and  divides  it  circularly  one  or  two  mm.  from  the  corneo- 
scleral  border.  This  incision  of  the  conjunctiva,  which 
extends  two-thirds  around  the  circumference  of  the  cornea, 
is  made  in  two  equally  divided  cuts,  the  first  below  and 
the  second  above,  from  the  point  of  fixation.  The  separated 
conjunctiva  and  capsule  of  Tenon  are  pushed  back  with 
the  fixation  forceps  or  closed  scissors,  and  the  tendon  of 
the  internal  rectus  grasped,  divided  posterior  to  the  forceps, 
and  held  until  the  operation  is  finished.  One  blade  of  the 
straight  conjunctival  scissors  is  passed  beneath  the  inferior 
rectus  and  the  two  blades  brought  together,  dividing  the 
muscle.  The  superior  rectus  is  divided  in  a  similar  manner. 
The  enucleation  scissors  (Fig.  108)  are  now  passed  back- 
ward, with  the  points  closed  and  hugging  the  sclera  until 
the  optic  nerve  is  reached,  which  is  then  divided.  The 
ball  is  now  easily  rotated  outward  and  as  it  turns  every 
tissue  clinging  to  the  sclera  is  divided  and  left  in  the  orbit. 
Hemorrhage  is  checked  by  pads  of  absorbent  cotton,  con- 


214  A    MANUAL    OF    CLINICAL   OPHTHALMOLOGY. 

fined  by  a  roller  bandage,  which  is  drawn  tight  enough  to 
exercise  a  moderate  degree  of  pressure.  This  dressing  is 
not  changed  for  twenty-four  hours.  At  the  expiration  of 
that  time  it  is  removed,  the  parts  cleansed  with  a  bichloride 
wash,  and  a  new  dressing  of  a  similar  kind  applied.  The 
bandage  may  be  discarded  on  the  third  or  fourth  day,  and 
a  saturated  solution  of  boric  acid  given  the  patient  with 
instruction  to  bathe  the  orbit  two  or  three  times  a  day 
until  the  wound  is  entirely  healed.  As  a  rule,  an  artificial 
eye  may  be  worn  after  the  lapse  of  four  weeks. 

SYMBLEPHARON. — If  the  band  holding  the  ball  and  the  lid 

FIG.  108. 


EKUCLEATION  SCISSORS. 

together  is  narrow,  it  may  be  separated  by  an  enveloping 
lead  ligature,  tightly  twisted,  which  is  allowed  to  cut  its  way 
through.  When  this  is  accomplished  the  ocular  extremity 
of  the  adhesion  is  removed  and  the  part  sutured  (Fig.  109). 
When  the  adhesion  is  broad  it  is  separated,  under  tension, 
from  its  ocular  attachment  by  the  knife  or  scissors.  A 
thread  armed  with  two  needles  is  passed  through  the 
divided  end  of  the  cicatricial  tissue.  The  needles  are 
carried  from  the  bottom  of  the  cul-de-sac  from  within 
outward  through  the  lid,  the  thread  drawn  tight  over  a 
small  pad  and  tied,  and  the  divided  ocular  conjunctiva 
sutured  (Fig.  1 10). 


OPERATIONS. 


215 


ANKYLOBLEPHARON. — The  adhesions  must  be  separated 
by  knife   or  scissors,  having  first  ascertained  their  extent 

FIG.  109. 


OPERATION  FOR   SYMBLEPHARON  BY  THE  INTRODUCTION  OF  A 
LEADEN  THREAD. 


FIG.  no. 


ARLT'S  METHOD. 


by  passing  a  probe,  and  the  lids   kept  apart  by  traction 
during  the  healing  process. 


2l6  A    MANUAL   OF   CLINICAL   OPHTHALMOLOGY. 

CANTHOTOMY. — The  temporary  widening  of  the  palpebral 
commissure,  consists  in  introducing  one  blade  of  the  enucle- 
ation  scissors  into  the  conjunctival  sac  at  the  outer  angle  of 
the  commissure  and  carrying  it  toward  the  temporal  side 
until  it  has  reached  the  margin  of  the  orbit,  and  then 
bringing  the  two  blades  of  the  scissors  together,  dividing 
skin,  fat,  orbicularis  muscle,  subconjunctival  connective 

FIG.  i  ii. 


CANTHOPLASTY. 

tissue  and  the  conjunctiva.  This  operation  is  of  great 
benefit  in  chronic  catarrhal  conjunctivitis  with  corneal  ulcer. 
CANTHOPLASTY  (Fig.  1 1 1). — The  object  of  this  operation 
is  to  permanently  widen  the  palpebral  commissure.  The 
tissues  are  divided,  as  in  the  operation  of  canthotomy  just 
described,  by  a  single  cut  with  the  scissors,  and  the  raw 
margins  of  the  divided  skin  and  conjunctiva  brought  together 
by  three  sutures,  the  first  uniting  the  parts  in  the  angle  of 


OPERATIONS. 


2I7 


the  cut,  the  second  and  third  sutures  uniting  them  on  the 
lower  and  upper  lid  in  the  order  named. 

TARSORRAPHY  (Fig.  112)  is  the  operation  for  shortening, 


FIG.  112. 


FIG.  113. 

£/>.  YARNALL  CO.FHILA 


HORN  PLATE. 


FIG.  114. 


LID  FORCEPS. 


or  altogether  closing  the  palpebral  aperture.     It  consists  in 
stretching  the  upper  lid  over  a  horn  plate  (Fig.  1.13)  or  lid 
forceps  (Fig.  1 14),  and  removing  with  a  small  iridectomy 
19 


2l8  A    MANUAL   OF  CLINICAL   OPHTHALMOLOGY. 

knife  a  flap,  I  mm.  broad  from  its  free  margin,  the  desired 
distance  toward  the  outer  canthus,  ab  Fig.  112,  including 
the  hair  bulbs.  The  excision  is  extended  2-3  mm.  over 
the  inner  border,  in  order  to  insure  close  union  of  the 
parts  in  exact  juxtaposition.  The  lower  lid  is  similarly 
treated  and  the  raw  surfaces  of  the  two  lids  are  brought 
together  by  fine  sutures.  The  eye  is  bandaged  and  kept 
shut  until  the  wound  unites  ;  the  sutures  are  then  removed. 

Fie.   115. 


OPERATION  FOR  DISTICH  IASIS. 

EXCISION  OF  CILI;E  (Fig.  115)  is  sometimes  performed 
for  the  relief  of  distichiasis.  The  operation  is  simple,  and 
usually  effective.  The  lid  is  elevated  by  a  horn  or  lid 
forceps,  and  an  incision  2  mm.  deep  made  between  the 
tarsus  and  skin  in  the  edge  of  the  lid  from  one  canthus  to 
the  other.  A  second  incision  of  the  same  length  is  made 
through  the  skin  2  mm.  from  the  border  down  to  the 
tarsus.  The  portion  of  skin  and  fascia  thus  separated  and 


OPERATIONS.  219 

removed,  should  include  the  bulbs  of  the  ciliae,  but  not 
the  meibomian  glands.  Suturing  is  not  necessary. 

ENTROPION. — The  skin  overlying  the  centre  of  the  upper 
border  of  the  tarsus  is  nicked  and  lid  forceps  inserted. 
Commencing  at  the  indentation  thus  made  and  passing 
horizontally  right  and  left,  the  upper  half  of  the  cartilage  is 
cleared  its  entire  width  by  division  of  the  skin,  connective 
tissue  and  muscle  which,  after  division,  are  pushed  toward 
the  ciliary  border.  A  suture  is  passed  from  below  upward 
through  the  pad  of  tissues  thus  formed,  and  carried 
through  the  upper  border  of  the  exposed  cartilage.  Fixa- 
tion forceps,  held  in  the  left  hand,  are  now  thrust  backward 
and  upward  to  grasp  the  relaxed  levator  palpebrae  tendon, 
which  is  drawn  forward.  Finally,  the  needle  is  thrust 
through  the  tendon  thus  advanced,  and  the  two  ends  of  the 
thread  tied.  Two  lateral  sutures,  one  at  either  side  of  the 
first,  are  carried  through  the  mass,  in  a  similar  manner,  and 
tied. 

ECTROPION  (Figs.  116  and  117). — In  eversion  of  the  lid, 
some  form  of  plastic  operation  is  usually  necessary.  As  a 
rule,  a  V-shaped  excision  of  a  part  of  the  lid  is  made,  and 
skin  from  below  brought  in  its  place  and  held  by  sutures. 
Occasionally  it  will  be  found  sufficient  to  cauterize  with  a 
hot  iron  the  everted  conjunctiva,  which  will  slough  and 
leave  a  cicatrix  extensive  enough  to  maintain  the  lid 
in  its  proper  position.  Or,  instead  of  the  hot  iron  cautery, 
caustics  may  be  employed  to  destroy  the  indurated  and 
hypertophied  conjunctiva,  and  to  form  the  necessary  cica- 
trix. 

CHALAZION. — The  removal  of  these  bodies  is  the  same 
as  for  cysts  in  other  situations  of  the  body.  A  chalazion 
can  readily  be  dissected  out  from  the  conjunctival  surface 
as  a  rule,  and  when  practicable  this  surface  should,  for 


220 


A    MANUAL   OF    CLINICAL    OPHTHALMOLOGY. 


obvious  reasons,  be  selected.    The  lid  is  secured  by  forceps, 
the  cyst  incised,  emptied,  and  an  obliterative  inflammation 


FIG.  1 1 6. 


OPERATION  FOR  ECTROPION  :  THE  INCISION. 


FIG.  117. 


OPERATION  FOR  ECTROPION:  THE  SUTURES  IN  POSITION. 


of  its  walls  induced  by  the  application  of  the  solid  stick  of 
silver  nitrate,  or  by  crystals  of  copper  sulphate.     Under  this 


OPERATIONS.  221 

treatment,  all  signs  of  the  tumor,  and  of  the  consequent 
inflammation,  disappear. 

PTOSIS. — The  simplest  and  most  effective  operation,  con- 
sists in  passing  a  stout  silk  ligature  vertically  under  the  skin 
from  the  eyebrows  to  the  margin  of  the  lids,  and  firmly 
tying  the  ends.  The  noose  thus  formed  is  daily  tightened 
until  it  has  cut  its  way  through  the  confined  tissues.  The 
resulting  cicatrix  restores  and  holds  the  lid  in  its  normal 
position. 

STRICTURE  OF  THE  LACRYMAL  DUCT. — The  lower  lid  is 
made  tense  and  the  point  of  a  Weber  Knife  (Fig.  118) 
introduced  vertically  into  the  punctum,  its  handle  lowered 
until  it  is  brought  into  a  horizontal  position,  and  the  blade 

FIG.  ii  8. 


CANALICULUS  KNIFE. 

of  the  instrument  with  its  cutting  edge  upward,  thrust 
forward  until  it  comes  in  contact  with  the  lacrymal  bone. 
The  handle  is  again  elevated  to  a  point  immediately  in 
front  of  the  supra-orbital  notch,  and  a  cut  made  along  the 
inner  and  free  margin  of  the  lid,  converting  the  canaliculus 
into  a  gutter.  The  point  of  the  knife  with  its  cutting  edge 
forward,  is  now  engaged  in  the  lacrymal  sac,  whence  it  is 
carried  downward,  backward  and  slightly  outward  into 
the  nasal  duct,  dividing  the  stricture. 

The  canal  thus  re-established  (Fig.  1 19)  should  be  main- 
tained for  a  time  by  the  daily  introduction  of  a  probe,  No. 
10,  Bowman  (Fig.  120).  After  the  lapse  of  a  week  or 
ten  days,  No.  8  or  6  probe  may  be  used,  and  the  intervals 


222  A    MANUAL   OF   CLINICAL   OPHTHALMOLOGY. 


FIG.   119. 


PROBING  THE  NASAL  DUCT. 


E.A:fARNALL  CO.  PHI  LA. 


OPERATIONS.  223 

of  its  introduction  gradually  increased  until  all  signs  of  ob- 
struction have  subsided. 

Various  operations  for  epithelioma,  ulcer,  naevi,  warty 
excrescences,  etc.,  have  been  suggested.  They  belong,  how- 
ever, to  the  domain  of  general  surgery.  The  ingenuity 
of  the  operator  and  his  knowledge  of  the  principles  of 
general  surgery,  must  be  relied  upon  to  devise  proper 
measures  for  their  relief. 

An  operating  case  suitable  for  operations  described  in 
this  volume  would  contain — 

Graefe  Knife,  straight  Keratome,  bent  Keratome,  Graefe 
Cystotome,  Small  Strabismus  Hook,  Bowman's  Stop 
Needle,  Speculum,  Double  Scoop,  Canaliculus  Knife, 
Curved  Iris  Forceps,  Fixation  Forceps,  Ciliae  Forceps, 
McClure's  Iris  Scissors,  Enucleation  Scissors,  Conjunctival 
Scissors,  Lid  Retractor,  Set  of  Bowman's  Probes,  Lid 
Forceps,  Horn  Plate,  Spud,  Lens  Extractor,  Needle 
Holder,  Needles  and  Silk.  Cost,  about  $35.00. 


INDEX. 


A. 

Abduction,  84 
Abscess  of  orbit,  193 
Accommodation,  31 

negative,  31 

positive,  31 

range  of,  32,  57 

relative,  33 

spasm  of,  76 

Achromatopsia,  acquired,  41 
Adduction,  84 

Advancement  of  tendon,  212 
Albinism,  147 
Alopecia,  113 
Amblyopia,  90 

tobacco  and  alcohol,  191 
Ametropia,  54 
Angle  a,  27 

7,  27 

metre,  33 

.  of  5',  34 
Aniridia,  147 

Ankyloblepharon,  116,  215 
Annulus  senilis,  130 
Aphakia,  145 
Arcus  senilis,  130 
Artery,  central  retinal,  17,  24 

anterior  ciliary,  24 

external  carotid,  23 

hyaloid,  18,  25,  137,  145,  164 

internal  carotid,  22 

lacrymal,  23 

long  ciliary,  24 

muscular,  24 

nasal,  24 

ophthalmic,  21 

palpebral,  24 

short  ciliary,  24 

supra-orbital,  24 


Atropine  sulphate,  76,  77 
Astigmatism,  59 

comp.  hyper.,  60,  63 

myopic,  60,  63 

diagnosis  and  treatment  of,  60 
by  ophthalmoscope,  67 
by  retinoscopy,  71 
hypermetropic,  60,  63 
irregular,  60,  63 
mixed, 60 
myopic,  60,  63 
regular,  60 
•     symptoms  of,  60 
Axis,  optic,  27 
principal,  47 
secondary,  47 
visual,  27,  33 

B. 

Blepharitis,  109 

angularis,  94 

marginalis,  94,  109 
Blepharospasm,  115 
Blepharophimosis,  116 
Blind  spot,  37 
Burns,  107 

C. 

Canal  of  Cloquet,  18 

of  Petit,  1 8 

of  Schlemm,  II,  24 
Canaliculi,  30 
Cancer,  melanotic,  132 
Canthoplasty,  216 
Canthotomy,  216 
Capsule,  anterior,  19 

deposits  on,  145 

Tenon's,  24,  25 

wounds  of,  145 


225 


226 


INDEX. 


Caruncula  lacryraalis,  29 
Caustics,  contraindicated,  94 
Cataract,  136 

acquired,  138 

anterior  polar,  136 

capsular,  129 

secondary,  145 
treatment  of,  146 

causes  of,  138 

central,  136 

clinical  features  of,  142 

congenital,  136 

cortical,  136 

extraction  of,  with  iridectomy, 

196 
without  iridectomy,  200 

fusiform,  137 

hard,  138 

history  of,  142 

incipient,  138 

lenticular,  129 

mature,  138 

nuclear,  138 

posterior  polar,  137,  147 

pyramidal  capsular,  136 

senile,  138 

secondary,  138 

soft,  138,  201 

spoon,  198 

total  congenital,  137 

traumatic,  143 

treatment  of,  143 

ripe,  142 

zonular  or  lamellar,  137 
Ciliae,  excision  of,  218 
Ciliary  body,  12 

circle,  14 

processes,  14 

region,  14 
Chalazion,  112,  219 
Chamber,  anterior,  18 

posterior,  18 

vitreous,  18 

Chancre  of  conjunctiva,  1 12 
Chi  asm,  optic,  21 
Chorea,  1 1 6 
Choroid,  1 1 

central  senile  atrophy  of,  158 

ophthalmoscopic  appearances  in 

disease  of,  158 
Choroiditis,  157 


rhoroiditis,  areolar,  158 

central,  158 

guttate,  158 

disseminated,  157 

retino-,  157 

symptoms  of.  in  general,  Ibl 
Cocaine  hydrochlorate,  77 
Coloboma  of  iris,  147 

of  lid,  1 06 
Color-blindness,  40 

sense,  39 
Colors,  39 

complementary,  39 

confusion  of,  39 

primary,  39 

secondary,  39 
Commissure,  optic,  21 
Conjunctiva,  29 

fornix  of,  29 

ocular,  29 

palpebral,  29 

hyperarmia  of,  92 

xerosis  of,  104 
Conjunctivitis,  92 

blennorrhoeal,  loo 

catarrhal,  acute,  93 
chronic,  94 

croupous,  103 

diphtheritic,  103 

follicular,  95 

gonorrhoeal,  100 

granular,  96 

herpetic,  102 

lymphatic,  102 

phlyctenular,  102 

purulent,  100 

scrophulosis,  102 

vernal,  95 
Contusion,  108 
Convergence,  27,  33 
Cornea,  10,  29 

abscess  of,  1 28 

conical,  124,  130,  206 

tattooing  of,  208 

tumors  of,  132 
Corneitis,  122 
Comeo-scleral  margin,  10 
Corpora  geniculata,  19 

quadragemini,  19 
Correction,  full,  of  ametropia,  56 
Cortex  of  lens,  19 


INDEX. 


227 


Critchett's  operation,  132,  133 
Crus  cerebri,  21 
Cyclitis,  154 

chronic,  155 
Cylinders,  48,  49 
Cystotome,  198 


D. 

Dacryocystitis,  119 

Depilation,  113 

Dermoid  cyst  of  conjunctiva,  105 

of  cornea,  132 
Descemitis,  151 
Deviation,  angle  of,  44 
Dilator  iridis,  14 
Diopter,  meaning  of,  36 
Dioptric  system,  49 
Diplopia,  80 
Distichiasis,  98,  112 
Double  vision,  117 
Duboisine  sulphate,  76 
Duct,  nasal,  31 


E. 

Ecchymosis,  112 
Ectropion,  115,  219 
Eczema  of  lids,  1 10 
Embolism  of  retinal  artery,  173 
Emergence,  angle  of,  43 
Emergent  ray,  43 
Emmetropia,  32,  53 

diagnosis  of,  by  retinoscopy,  70 
Emphysema,  no 
Enophthalmus,  194 
Entropion,  98,  114,  219 
Enucleation,  213 
Epicanthus,  106 
Epiphora,  118,  119 
Epithelioma,  III 
Erysipelas,  no 
Erythema,  1 10 
Esophoria,  83,  85 
Esotropia,  84,  90 
Exophoria,  83 
Exophthalmus,  194 
Exotropia,  84,  91 
Eyeball,  9 


F. 

Far  point,  32,  57,  58 
Focal  distance,  47 

length  of  eye,  49 
Focus,  principal,  47 

virtual,  48 
Foramen  sclera,  10,  21 

choroidea,  1 1 
Forceps,  fixation,  196 

iris,  197 
Foreign  bodies  in  anterior  chamber, 

209 

in  conjunctiva,  208 
in  cornea,  208 
in  lens,  209 

in  vitreous  chamber,  209 
Fossa,  hyaloid,  18 
Fovea  centralis,  17,  66 

G. 

Ganglion,  ophthalmic,  14,  21,  22 
Gland,  lacrymal,  30,  117 
abscess  of,  117 
fistule  of,  118 
hypertrophy  of,  117 
Glands,  Meibomian,  29 
Glaucoma,  acute  inflammatory,  170 
chronic  inflammatory,  167 
fulminating,  170 
secondary,  132, 133, 150,  171 
simple,  1 66 

Glaucomatous  degeneration,  171 
Glioma,  pseudo,  162 
Granuloma,  105 

H. 

Hemianopsia,  192 

bilateral,  192 

binasal,  192 

bitemporal,  192 

horizontal,  36 

vertical,  37,  192 
Herpes,  123, 125 

zoster,  ophthalmic,  125 
Heteronymous  images,  80 
Heterophoria,  83,  85 

diagnosis  of,  87 
Heterotropia,  84,  88 
Homatropine  hydrobromate,  76 


228 


INDEX. 


Homonymous  images,  80 
Hordeolum,  109 
Humor,  aqueous,  1 8 

vitreous,  18 
Hyalitis,  163 

Hyoscyamine  sulphate,  76 
Hyperesophoria,  83 
Hyperesotropia,  84 
Hyperexophoria,  83 
Hyperexotropia,  83 
Hypermetropia  (hyperopia),  27,  54, 

84 

accommodation  in,  57 

diagnosis  by  ophthalmoscope,  68 
by  retinoscopy,  70 

manifest,  55 

latent,  55,  57 

total,  55,  57 
Hyperphoria,  83,  85 
Hyphsemia,  spontaneous,  153 

traumatic,  153 
Hypopyon,i24, 128,  152 

I. 

Image,  false,  80,  tt  seq. 

true,  79,  89 
Incidence,  angle  of,  43 
Incident  ray,  43 
Iris,  14 

absence  of,  147 

colobomaof,  147 

cysts  of,  154 

detachment  of,  153 

granuloma  of,  154 

gumma  of,  154 

hyperamia  of,  147 

tubercle  of,  1 54 
Iridectomy,  202 
Iridotomy  (iritomy),  204 
Iritis,  129 

cause  of,  150 

chronic,  149 

parenchymatous,  152 

plastic,  148 

serous,  151 

suppurative,  152 

treatment  of,  1 50 

K. 

Keratitis,  interstitial,  127 
necrotic,  130 


Keratitis,  neuro-paralytic,  129 

parenchymalous,  127 

phlyctenular,  122 
Knife,  Graefe  cataract,  196 

iridectomy,  203 

iridotomy,  204 

paracentesis,  205 

L. 

Lacrymal  sac,  abscess  of,  119 
blennorrhoea  of,  119 
fistule  of,  1 20 
syringe,  120 
Lacrymation,  123 
Lamina  cribrosa,  10,  21 
Lens,  crystalline,  18,  31 
absence  of,  145 
concave,  44,  47 
convex,  44 
dislocation  of,  144 
extractor,  200 
Lenticular  ganglion,  14 
Leucoma,  130 
Lids,  27 

Lid  speculum,  196 
Ligament,  suspensory,  1 8 
Ligamentum  pectinatum  iridis,  14 
Limbus  corneie,  122 
Lipoma,  105 
Liquor  Morgagni,  18 
Lupus,  III 

Lymph  space  of  anterior  chamber,  24 
ciliary  body,  25 
conjunctiva,  25 
cornea,  25 
intervaginal,  21,  24 
perichoroid,  24,  25 
of  sclera,  25 
subdural,  21 
suprachoroidea;,  n 
of  Tenon's  capsule,  25 
retina,  25 
vitreous,  25 

M. 

Macula  lutea,  17 

of  cornea,  130 
Massage,  118,  120 
Melanoma,  132 
Melano-sarcoma,  105 


INDEX. 


229 


Membrane,  arachnoid,  21 

Bowman's,  10 

Descemet's,  10 

dura  mater,  21 

hyaloid,  1 8 
Microphthalmus,  147 
Milium,  112 
Muscse  volitantes,  163 
Muscle,  ciliary,  action  of,  31 

external  rectus,  25,  78 

inferior       "       25,  78 

internal       "       25,  78 

superior      "       25,  78 

inferior  oblique,  26,  78 

superior       "       25,  26,  78 

levator  palpebrse,  27,  29 

orbicularis  palpebrarum,  27,  29 

tendo  oculi,  31 

tarsi,  31 
Mydriasis,  artificial,  152 

emotional,  152 

idiopathic,  152 

symptomatic,  152 
Mydriatics,  75 
Myopia,  27,  57 

accommodation  in,  58 

acquired,  58 

congenital,  58 

diagnosis  by  ophthalmoscope,  67 
by  retinoscopy,  7 1 

high,  58 

low,  58 

moderate,  58 

staphyloma  in,  104 
Myosis,  artificial,  153 

irritative,  153 

paralytic,  153 

reflex,  153 

N. 

Nasal  duct,  stricture  of,  119 
Near  point,  32,  57,  58 
Nebula,  130 
Nerve,  optic,  atrophy  of,  189 

ophthalmoscopic  appearances 

of,  190 
Nerves,  1st,  2d,  3d,  4th,  5th,  6th,  7th 

lacrymal,  21,  22 
frontal  infra-trochlear  long  ciliary, 


Nerves,  nasal,  short   ciliary,  sympa- 
thetic, 21,  22 
Neuritis,  optic,  185 

retrobulbar,  188 
Neuro-retinitis,  187 
Nucleus  of  lens,  19 
Nystagmus,  81 

O. 

Ocular  muscles,  paralysis  of,  78 
physiology  of,  78 
scheme  of  action  of,  79 
strength  of,  84 

CEdema,  no 

Onyx,  124,  128 

Opacities,  corneal,  130 

Opaque  nerve- fibres,  175 

Ophthalmia,  neonatorum,  100 
sympathetic,  155 

Ophthalmoplegia  externa,  81 
interna,  81 

Ophthalmoscope,  examination  by,  50 
by  direct  method,  51,  64 
by  indirect  method,  52,  66 

Optical  centre,  47 

Ora  serrata,  II,  14,  17 

Orbit,  abscess  of,  193 
tumors  of,  193 

Orthophoria,  83 

Orthotropia,  83 

P. 

Pagenstecher's  ointment,  94 
Pannus,  98,  124 
Papilla,  66 
Papillitis,  1 86 
Paracentesis,  cornese,  205 
Paralysis  of  external  rectus,  8 1 

of  inferior  rectus,  81 

of  internal  rectus,  8l 

of  superior  rectus,  8 1 

of  superior  and  inferior  oblique, 

81 

Pediculus  pubis,  113 
Pericofneal  ring,  122 
Perimeter,  37 
Periostitis,  193 
Phlegmon,  108 
Phthisis  bulbi,  156 
Phlyctenule,  122,  123 


230 


INI'l.X. 


Photophobia,  123 
Pinguecula,  105 
Pink-eye,  93 
Placido'sdisc,  131 
Plica  semilunaris,  29 
Polycoria,  147 
Polypi,  105 

Porus  opticus,  17,  21,  24 
Presbyopia,  72 

in  E,  72 

in  H.  and  comp.  H.  As.,  73 

in  M.  and  comp.  M.  As.,  73 

in  mixed  astigmatism,  75 
Prisms,  33,  43 
Pterygium,  104,  212 
Ptosis,  acquired,  116 

congenital,  106 

operation  for,  221 
Puncta  lacrymalia,  30 

malposition  of,  118 
Pupil,  14 

Argyll  -  Robertson  ,153 

dilatation  of,  152 
Pupillary  membrane,  persistent,  145, 

147 
Purkinje's  sign,  145 

R. 

Reflection,  42 
Refracting  media,  49 

power,  47 
Refraction,  42 

determination  of,  by  ophthalmo- 
scope, 67 

index  of,  42, 49 

in  heterophoria,  86 

normal,  53 

ophthalmoscope,  64 
Retina,  15 

anaemia  of,  172 

anaesthesia  of,  183 

detachment  of,  181 

exposure  of,  to  light,  184 

glioma  of,  183 

hemorrhage  of,  174 

hypenemia  of,  172 

hypenesthesia  of,  183 

normal  sensibility  of,  37 
Retinitis,  albuminuric,  176 

central  acute,  182 


Retinitis,  diffused  chronic,  178 

hemorrhagic,  175 

pigmentosa,  179 
Retinoscopy,  56,  70 

S. 

Sac,  lacrymal,  31 
S;x'misch's  incision,  1 29,  205 
Sarcoma,  105,    132 
Scissors,  conjunct! val,  211 

De  Wecker's  iritomy,  205 

enucleation,2i4 

iridectomy,  197 
Sclera,  9 
Scleritis,  132 
Scotoma,  37 
Skin  grafting,  108 
Spaces  of  Fontana,  1 1 ,  24 
Sphincter  pupilbe,  14 
Squint,  alternating,  89 

concomitant,  89 

monolateral,  89 
Staphyloma,  99,  1 24 

ciliary,  133 

of  cornea,  131,  132,  206 

of  sclera,  133,206 

posterior,  133 

secondary,  135 
Strabismus,  88 

external,  91 

internal,  90 

hook,  210 

Stricture  of  lacrymal  duct,  221 
Stye,  109 
Style,  121 
Sulcus  sclera,  10 
Sursumduction,  84 
Symblepharon,  116,  214 
Synchisis,  163 

scintillans,  163 
Synechioe,  anterior,  126,  129 

partial,  149 

posterior,  148,  149 

total,  149 

T. 

Tarsorrhaphia,  217 
Tarsus,  27,  29 
Tenotomy,  91,  209 
graded,  2 1 1 


INDEX. 


Tension,  description  of,  169 
Test  card,  astigmatic,  61 

cards,  34 

lenses,  34 

cylinders,  36 

lens-holder,  36 

lenses,  spherical,  45 
Trichiasis,  112 
Trachoma,  96 
Tracts,  optic,  19 


U. 

Ulcer,  deep,  124 
resorption,  124 
rodent,  no 
serpiginous,  127 

Uvea,  14 


V. 

Veni,  ophthalmic,  21 
Venae  vorticosse.  12 
Vision,  acuity  of,  34 
field  of,  36,  37 
Vitreous  chamber,  18,  164 

foreign  bodies  in,  164 

W. 

Warty  excrescences,  223 
Wire  loop,  200 
Worsteds,  Holmgren's,  60 

X. 

Xanthelasma,  112 


Z. 


Zone  of  Zinn,  14 


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Chief  Chemist  Board  of  Health,  Brooklyn,  N.  Y.,  etc. 
With  Glossary  and  Illustrations.  684  pages. 

"  It  is  with  pleasure  that  we  notice  what  is  probably  the  best 
chemistry  for  medical  students — for  its  size — now  in  the  market. 
Prof.  Hartley  has  written  the  book  because  he  had- something  to 
say;  and  he  has  said  it  well." — The  Journal  of  the  American 
Medical  Association,  Chicago,  III. 

Price  of  each  Book,  Cloth,  $3.00;  Leather,  $3.50. 


STUDENTS'  TEXT-BOOKS  AND  MANUALS. 


ANATOMY. 

Morris'  New  Text-Book  on  Anatomy.  Now  Rtady.  By 
ten  leading  Surgeons  and  Anatomists,  and  Edited  by  Henry 
Morris,  F.R.C.S.  791  Specially  Engraved  Illustrations,  214  of 
which  are  printed  in  colors.  Octavo.  1280  pages. 

Price  in  Cloth,  7.50;  Sheep,  8.50;  Half  Russia,  9.50 
'»•  Send  for  Descriptive  Circular  and  Sample  Pages. 

Macalister's  Human  Anatomy.  816  Illustrations.  A  new 
Text-book  for  Students  and  Practitioners,  Systematic  and  Topo- 
graphical, including  the  Embryology,  Histology, and  Morphology 
of  Man.  With  special  reference  to  the  requirements  of 
Practical  Surgery  and  Medicine.  With  816  Illustrations, 
400  of  which  are  original.  Octavo.  Cloth,  7.50;  Leather,  8.50 

Ballou's  Veterinary  Anatomy  and  Physiology.  Illustrated. 
By  Wm.  R.  Ballon,  M.D.,  Professor  of  Equine  Anatomy  at  New 
York  College  of  Veterinary  Surgeons.  29  graphic  Illustrations. 
I2mo.  Cloth,  i. oo ;  Interleaved  (or  notes,  1.25 

Holden's  Dissector.  A  manual  of  Dissection  of  the  Human 
Body.  Sixth  Edition.  Edited  by  A.  Hewson,  M.D.,  Demonstra- 
tor of  Anatomy  at  Jefferson  Medical  College.  311  Illustrations, 
many  of  which  are  new.  Oil-cloth,  3.00;  Sheep,  3.50 

Holden's  Human  Osteology.  Comprising  a  Description  of  the 
Bones,  with  Colored  Delineations  of  the  Attachments  of  the 
Muscles.  The  General  and  Microscopical  Structure  of  Bone  and 
its  Development.  With  Lithographic  Plates  and  Numerous  Illus- 
trations. Seventh  Edition.  8vo.  Cloth,  6.00 

Holden's  Landmarks,  Medical  and  Surgical.   4th  Ed.  Clo.,i.2S 

Potter's  Compend  of  Anatomy.  Fifth  Edition.  Enlarged. 
16  Lithographic  Plates.  117  Illustrations.  Stt pagt  14. 

Cloth,  i.oo;  Interleaved  for  Notes,  1.25 

CHEMISTRY. 

Hartley's  Medical  and  Pharmaceutical  Chemistry.  Third 
Edition.  Prepared  specially  for  Medical,  Pharmaceutical,  and 
Dental  Students.  60  Illustrations,  Plate  of  Absorption  Spectra, 
and  Glossary.  Revised  and  Enlarged.  Cloth,  3.00 

Trimble.  Practical  and  Analytical  Chemistry.  A  Course  in 
Chemical  Analysis,  by  Henry  Trimble,  Prof,  of  Analytical  Chem- 
Utry  in  the  Phila.  College  of  Pharmacy.  Illustrated.  Fourth 
Edition,  Enlarged.  8vo.  Cloth,  1.50 

Bloxam's  Chemistry,  Inorganic  and  Organic,  with  Experiments. 
Eighth  Edition.  a8i  Illustrations.  In  Prets 

Iff  Sft  paget  2  to  3  for  list  of  StuJentt' Maintalt . 


STUDENTS'  TEXT-BOOKS  AND  MANUALS.         7 

Chemistry  : —  Continued. 

Richter's  Inorganic  Chemistry.  Fourth  American,  from  Sixth 
German  Edition.  Translated  by  Prof.  Edgar  F.  Smith,  PH.D. 
89  Wood  Engravings  and  Colored  Plate  of  Spectra.  Cloth,  3.00 

Richter's  Organic  Chemistry,  or  Chemistry  of  the  Carbon 
Compounds.  Illustrated.  Second  Edition.  Cloth,  4. 50 

Sy  monds.  Manual  of  Chemistry,  for  the  special  use  of  Medi- 
cal Students.  By  BRANDRBTH  SYMONDS,  A.M.,  M.D.,  Asst. 
Physician  Roosevelt  Hospital,  Out- Patient  Department ;  Attend- 
ing Physician  Northwestern  Dispensary,  New  York.  Cloth,  2.00 

Leffmann's    Compend    of   Medical    Chemistry.      Including 
Urinary  Analysis.     Fourth  Edition.     Revised. 
See  page  15.  Cloth,  i.oo;   Interleaved  for  Notes,  1.23 

Muter.  Practical  and  Analytical  Chemistry.  Fourth  Edi- 
tion. Revised,  to  meet  the  requirements  of  American  Medical 
Colleges,  by  Prof.  C.  C.  Hamilton.  Illustrated.  Cloth,  1.25 

Holland.  The  Urine,  Gastric  Contents,  Common  Poisons, 
and  Milk  Analysis,  Chemical  and  Microscopical.  For  La- 
boratory Use.  Fifth  Edition,  Enlarged.  Illustrated.  Cloth,  1.25 

Woody.  Essentials  of  Chemistry  for  the  Medical  Student. 
Third  Edition.  Cloth,  1.25 

CHILDREN. 

Goodhart  and  Starr.  The  Diseases  of  Children.  Second 
Edition.  By  J.  F.  Goodhart,  M.D.,  Physician  to  the  Evelina 
Hospital  for  Children;  Assistant  Physician  to  Guy's  Hospital, 
London.  Revised  and  Edited  by  Louis  Starr,  M.D.,  Clinical 
Professor  of  Diseases  of  Children  in  the  Hospital  of  the  Univer- 
sity of  Pennsylvania;  Physician  to  the  Children's  Hospital, 
Philadelphia.  Containing  many  Prescriptions  and  Formulae, 
conforming  to  the  U.  S.  Pharmacopoeia,  Directions  for  making 
Artificial  Human  Milk,  for  the  Artificial  Digestion  of  Milk,  etc. 
Illustrated.  .  Cloth,  3.00;  Leather,  3.50 

Hatfield.  Diseases  of  Children.  By  M.  P.  Hatfield,  M.D., 
Professor  of  Diseases  of  Children,  Chicago  Medical  College. 
Colored  Plate,  izmo.  Cloth,  i.oo;  Interleaved,  1.25 

Starr.  Diseases  of  the  Digestive  Organs  in  Infancy  and 
Childhood.  With  chapters  on  the  Investigation  of  Disease, 
and  on  the  General  Management  of  Children.  By  Louis  Starr, 
if.D.,  Clinical  Professor  of  Diseases  of  Children  in  the  Univer- 
sity of  Pennsylvania.  Illus.  Second  Edition.  Cloth,  2.25 
4^-  Set  pages  14  and  15  for  list  offQuiz-Compendtf 


8          STUDENTS'  TEXT-BOOKS  AND  MANUALS. 

DENTISTRY. 

Fillcbrown.     Operative  Dentistry.     330  Illus.  Cloth,  2.50 

Flagg's  Plastics  and  Plastic  Filling.    4th  Ed.         Cloth,  4.00 
Gorgas.     Dental  Medicine.     Fifth  Edition.  Cloth,  4.00 

Harris.   Principles  and   Practice  of   Dentistry.    Including 
Anatomy,  Physiology,  Pathology,  Therapeutics,  Dental  Surgery 
and   Mechanism.     Twelfth  Edition.     Revised  and  enlarged  by 
Professor  Gorgas.     1028  Illustrations.  Cloth,  7.00  ;  Leather,  8.00 
Richardson's    Mechanical    Dentistry.      Sixth  Edition.     By 
Warren.    600  Illustrations.     8vo.          Cloth,  4.50;  Leather,  5.50 
Sewill.     Dental  Surgery.     200  Illustrations.     3d  Ed.   Clo.,  3.00 
Taft's  Operative  Dentistry.  100  Illus.  Cloth, 4. 25;  Leather, 5.00 
Talbot.      Irregularities   of  the   Teeth,  and   their  Treatment. 
Illustrated.     8vo.     Second  Edition.  Cloth,  3.00 

Tomes'  Dental  Anatomy.    Fourth  Ed.     235  Illus.     Cloth,  4.00 
Tomes'  Dental   Surgery.      3d  Edition.     292  Illus.    Cloth,  5.00 
Warren.    Compend  of  Dental  Pathology  and  Dental  Medi- 
cine.    Illustrated,     ad  Ed.  Cloth,  i.oo;   Interleaved,  1.2$ 
Warren.     Dental  Prostheses  and  Metallurgy.     129  Illustra- 
tions.     I2H10.  I.5O 

DICTIONARIES. 

Gould's  Student's  Medical  Dictionary.  Containing  the  Defi- 
nition and  Pronunciation  of  all  words  in  Medicine,  with  many 
useful  Tables,  etc. 

J4  Dark  Leather,  3.25  ;  %  MOT.,  Thumb  Index,  4.23 
Gould's  Pocket  Dictionary.     12,000  Medical  Words  Pro- 
nounced  and    Defined.      Containing   many   Tables   and   an 
Elaborate  Dose  List.    Thin  64010. 

Leather,  gilt  edges,  i.oo;  with  Thumb  Index,  1.25 

Harris'  Dictionary  of  Dentistry.  Fifth  Edition.  Completely 
revised  by  Prof.  Gorgas.  Cloth,  5.00;  Leather,  6.00 

Cleaveland's  Pronouncing  Pocket  Medical  Lexicon.  Small 
pocket  size.  Cloth,  red  edges  .75  ;  pocket-book  style,  i.oo 

Longley's  Pocket  Dictionary.  The  Student's  Medical  Lexicon, 
giving  Definition  and  Pronunciation,  with  an  Appendix  giving 
Abbreviations  used  in  Prescriptions,  Metric  Scale  of  Doses,  etc. 
24010.  Cloth,  i.oo;  pocket-book  style,  1.95 

EYE. 

Hartridge  on  Refraction.     ?th  Edition.     Illus.  Cloth,  1.75 

Swanzy.    Diseases  of  the  Eye  and  their  Treatment.    176 

Illustrations.     Fourth  Edition.  Cloth,  300;  Leather,  3.50 

Pox  and  Gould.    Compend  of  Diseases  of    the   Eye  and 

Refraction.    2d  Ed.     Enlarged.    71  Illus.    39  Formulae. 

Cloth,  i.oo;  Interleaved  for  Notes,  1.25 

*»-  .S>«  fiaget  a  to  5  for  Hit  of  Studtnts'  Manuals. 


STUDENTS'  TEXT-BOOKS  AND  MANUALS.          9 

ELECTRICITY. 

Bigelow.    Plain  Talks  on  Medical  Electricity.  Cloth,  i.oo 

Mason's  Compend  of  Medical  Electricity.  Cloth,  i.oo 

Steavenson  and  Jones.    Medical  Electricity.  A  Practical 

Handbook.     Illustrated.     i2mo.  Cloth,  2. 50 

HYGIENE. 

Coplin  and  Bevan.  Practical  Hygiene.  By  W.  M.  L.  Cop- 
lin,  Adjunct  Professor  of  Hygiene,  Jefferson  Medical  College, 
Philadelphia,  and  Dr.  D.  Bevan.  Illustrated.  Cloth,  4.00 

Parkes'  (Ed.  A.)  Practical  Hygiene.  Seventh  Edition,  en- 
larged. Illustrated.  8vo.  Cloth,  4.50 

Parkes'  (L.  C.)  Manual  of  Hygiene  and  Public  Health. 
Second  Edition.  121110.  Cloth,  2.50 

Wilson's  Handbook  of  Hygiene  and  Sanitary  Science. 
Seventh  Edition.  Revised  and  Illustrated.  Cloth,  3.25 

MATERIA  MEDICA  AND  THERAPEUTICS. 

Potter's  Compend  of  Materia  Medica,  Therapeutics,  and 
Prescription  'Writing.  Sixth  Edition,  revised  and  improved 
in  accordance  with  U.  S.  P.  1890.  See  page  If. 

Cloth,  i.oo;  Interleaved  for  Notes,  1.25 

Davis.  Essentials  of  Materia  Medica  and  Prescription 
Writing.  By  J.  Aubrey  Davis,  M.D.,  Demonstrator  of  Obstet- 
rics and  Quiz-Master  on  Materia  Medica,  University  of  Penn- 
sylvania, tamo.  Interleaved.  Net,  1.50 

Biddle's  Materia  Medica.  Thirteenth  Edition.  By  the  late 
John  B.  Biddle,  M.D.  Revised  by  Clement  Biddle,  M.D.  8vo. 
Illustrated.  Cloth,  net,  4.00  ;  Leather,  net,  5.00 

Potter.  Handbook  of  Materia  Medica,  Pharmacy,  and 
Therapeutics.  Including  Action  of  Medicines,  Special  Thera- 
peutics, Pharmacology,  etc.  By  Saml.  O.  L.  Potter,  M.D., 
M.R.C.P.  (Lond.),  Professor  of  the  Practice  of  Medicine  in 
Cooper  Medical  College,  San  Francisco.  Fifth  Revised  and 
Enlarged  Edition.  800  pages.  8vo.  Cloth,  4.50;  Leather,  5.50 

Sayre.  Organic  Materia  Medica  and  Pharmacognosy. 
A  Handbook  for  Students  of  Pharmacy  and  Medicine.  By 
L.  E.  Sayre,  PH.G.,  Professor  of  Pharmacy  and  Materia  Medica, 
University  of  Kansas ;  Member  Committee  of  Revision  of  U. 
S.  P.  543  Illustrations.  8vo.  Cloth,  4.50 

*S-  See  pages  14  and  15  /or  list  of  t  Quit-Contpendt  f 


10       STUDENTS'  TEXT-BOOKS  AND  MANUALS. 

White  and  Wilcox.  Materia  Medica,  Pharmacy.  Phar- 
macology, and  Therapeutics.  Second  American  Edition. 
By  Win.  Hale  White,  M.U.,  F.R.C.P.,  etc..  Physician  to  and 
Lecturer  on  Materia  Medica,  Gay's  Hospital.  Revised  by 
Reynold  W.  Wilcox,  M.D..LI..D  ,  Prof,  of  Clinical  Medicine  and 
Therapeutics  at  the  New  York  Post  Graduate  Medical  School. 
Visiting  Physician  St.  Mark's  Hospital,  etc.  Clo.,3.oo;  Lea. ,3.50 

MEDICAL  JURISPRUDENCE. 

Reese.  A  Text-book  of  Medical  Jurisprudence  and  Toxi- 
cology. By  John  J.  Reese.  M.D.,  Prof,  of  Medical  Jurispru- 
dence and  Toxicology  in  the  Medical  Depart.,  University  of 
Pennsylvania.  Fourth  Edition.  Revised  by  Henry  Leffmann, 
M.D.,  Prof,  of  Chemistry,  Pennsylvania  College  ot  Dentistry; 
Hygienist  and  Food  Inspector,  State  Board  of  Agriculture,  etc. 

Cloth,  3.00 ;  Leather,  3.50 

NERVOUS  DISEASES. 

Cowers.  Manual  of  Diseases  of  the  Nervous  System. 
A  Complete  T_ext-book.  By  William  R.  Cowers,  M.D.,  Prof. 
Clinical  Medicine,  University  College,  London.  Physician  to 
National  Hospital  for  the  Paralyzed  and  Epileptic.  Second 
Edition.  Revised,  Enlarged,  and  in  many  parts  Rewritten. 
With  many  new  Illustrations.  Octavo. 

VOL.  I.      Diseases  of  the  Nerves  and  Spinal  Cord.     616 

pages.  Cloth,  3.50 

VOL.  II.    Diseases  of  the    Brain  and  Cranial   Nerves. 

General  and  Functional  Diseases,  1069  pages.  Cloth, 4.50 

Ormerod.  Diseases  of  Nervous  System,  Student's  Guide  to. 
By  J.  A. Ormerod,  M.D.,  Oxon.,  F.R.C.P.  (London),  Mem.  Path.. 
Clin.,  Ophthal.,  and  Neurological  Societies;  Phys.  to  National 
Hospital  for  Paralyzed  and  Epileptic;  Dem.  of  Morbid  Anatomy, 
St.  Bartholomew's  Hospital,  etc.  75  Illustrations.  Cloth,  2.00 

OBSTETRICS  AND  GYNAECOLOGY. 

Davis.  A  Manual  of  Obstetrics.  By  Edw.  P.  Davis,  Clinical 
Lecturer  on  Obstetrics,  Jefferson  Medical  College,  Philadelphia. 
16  Plates,  and  134  Illustrations,  izmo.  id  Edition.  Cloth,  2.50 

Byford.  Diseases  of  Women.  By  W.  H.  Byford.M.o.,  Prof, 
of  Gynaecology  in  Rush  Medical  College,  and  H.  T.  Byford, 
M.D.,  Surgeon  to  the  Woman's  Hospital,  Chicago.  Fourth  Edi- 
tion. Enlarged.  306  1 11  us.  Octavo.  Cloth,  a.oo  ;  Leather,  8.50 

Lewers'  Diseases  of  Women.  A  Practical  Text-book.  139 
Illustrations.  Second  Edition.  Cloth,  2.50 

Wells.      Compend  of  Gynaecology.     Illustrated.      Cloth,  i.oo 

Winckel's  Obstetrics.  A  Text-book  on  Midwifery,  includ- 
ing the  Diseases  of  Childbed.  By  Dr.  F.  Winckel.  Author- 
ized Translation,  by  J.  Clifton  Edgar,  M.D.,  Lecturer  on  Ob- 
stetrics, University  Medical  College,  New  York.  Nearly  aoo 
handsome  Illustrations.  8vo.  Cloth,  6.00;  Leather,  7.00 

49-  Sfe  faff*  a  to  y/or  litt  a/Nen<  tfaMua.lt. 


STUDENTS'   TEXT-BOOKS  AND   MANUALS.         11 

Obstetrics  and  Gynaecology  : — Continued. 
Parvin's  Winckel's  Diseases  of 'Women.    Second  Edition. 

Including  a  Section  on  Diseases  of  the  Bladder  and  Urethra. 

150  Illus.     Revised.     See  page  3.  Cloth,  3.00;  Leather,  3.50 

Landis'  Compend    of   Obstetrics.      Illustrated,     sth  Edition, 

Enlarged.     By  Wells.      Cloth,  i.oo  ;   Interleaved  for  Notes',  1.25 

PATHOLOGY,  HISTOLOGY,  ETC. 

Stirling.  Outlines  of  Practical  Histology.  A  Manual  for 
Students,  zd  Edition.  368  Illustrations.  I2mo.  Cloth,  3.00 

Reeves.     Medical  Microscopy.     Colored  Illustrations. 

Cloth,  net,  2.50 

Wethered.  Medical  Microscopy.  By  Frank  J.  Wethered. 
M.D.,  M.R.C.P.  98  Illustrations.  Cloth,  2.50 

Hall.  Compend  of  General  Pathology  and  Morbid  Anat- 
omy. 91  very  fine  Illustrations.  Cloth,  i.oo;  Interleaved,  1.25 

Gilliam's  Essentials  of  Pathology.    47  Illus.  Cloth,  .75 

Virchow's  Post-Mortem  Examinations.    3d  Ed.    Cloth,  i.oo 

PHYSICAL  DIAGNOSIS. 

Tyson's  Student's  Handbook  of  Physical  Diagnosis.  Illus- 
trated. Second  Edition,  Enlarged.  i2mo.  Cloth,  1.50 

PHYSIOLOGY. 

Yeo's  Physiology.  Sixth  Edition.  The  most  Popular  Stu- 
dents' Book.  By  Gerald  F.  Yeo,  M.D.,  F.R.C.S.,  Professor  of 
Physiology  in  King's  College,  London.  Small  Octavo.  234 
carefully  printed  Illustrations.  With  a  Full  Glossary  and  Index. 
See  page  3.  Cloth,  3.00;  Leather,  3.50 

Brubaker's  Compend  of  Physiology.  Illustrated.  Seventh 
Edition.  Cloth,  i.oo;  Interleaved  for  Notes,  1.25 

Kirke's  Physiology.  New  13*  Ed.  Thoroughly  Revised  and 
Enlarged.  502  Illustrations,  some  of  which  are  printed  in  colors. 
(Blakiston's  Authorized  Edition.)  Red  Cl. ,  4.00 ;  Leather,  5.00 

Landois'  Human  Physiology.  Including  Histology  and  Micro- 
scopical Anatomy,  and  with  special  reference  to  Practical  Medi- 
cine. Fourth  Edition.  Translated  and  Edited  by  Prof.  Stirling. 
845  Illustrations.  2  vols.  Cloth,  net,  7.00 

PRACTICE. 

Taylor.  Practice  of  Medicine.  A  Manual.  By  Frederick 
Taylor,  M.D.,  Physician  to,  and  Lecturer  on  Medicine  at,  Guy's 
Hospital,  London ;  Physician  to  Evelina  Hospital  for  Sick  Chil- 
dren, and  Examiner  in  Materia  Medica  and  Pharmaceutical 
Chemistry,  University  of  London.  Cloth,  2.00;  Leather,  2.50 

Roberts'  Practice.  Revised  Edition.  A  Handbook  of  the 
Theory  and  Practice  of  Medicine.  By  Frederick  T.  Roberts, 
M.D.,  M.R.C.P.,  Professor  of  Clinical  Medicine  and  Therapeutics 
in  University  College  Hospital,  London.  Ninth  Edition. 
Octavo.  Cloth,  5.00 ;  Sheep,  6.co 

et  pages  14  and  15  for  list  of  f  Quiz- Commends  f 


12       STUDENTS'  TEXT-BOOKS  AND  MANUALS. 

Practici : —  Continued. 

Hughes.  Compend  of  the  Practice  of  Medicine.  5th  Edi- 
tion, Enlarged. 

Two  parts,  each,  Cloth,  i.oo;  Interleaved  for  Notes,  1.25 
PART  i. — Continued,  Eruptive  and  Periodical  Fevers,  Diseases 

of  the  Stomach,  Intestines,  Peritoneum,  Biliary  Passages,  Liver, 

Kidneys,  etc.,  and  General  Diseases,  etc. 
PART   n. — Diseases  of   the   Respiratory   System,   Circulatory 

System,  and  Nervous  System  :  Diseases  of  the  Blood,  etc. 
Physicians'  Edition.    Fifth  Edition.    Including  a  Section 
on  Skin  Diseases.  With  Index,    i  vol.  Full  Morocco,  Gilt,  2. 50 

from  John  A.  Robinson,  M.D.,  Assistant^  to  Chair  of  Clinical 
Medicine,  now  Lecturer  on  Materia  Mtdica,  Rusk  Medical  Col- 
lege, Chicago. 
"Meets  with   my  hearty  approbation  as  a  substitute  for  the 

ordinary  note  books  almost  universally  used  by  medical  students. 

It  is  concise,  accurate,  well  arranged,  and  lucid,    .     .     .    just  the 

thing  for  students  to  use  while  studying  physical  diagnosis  and  the 

more  practical  departments  of  medicine. 

Wythe's  Dose  and   Symptom  Book.    Containing  the  Doses 

and  Uses  of  all  the  principal  Articles  of  the  Materia  Medica,  etc. 

Seventeenth  Edition.    Completely  Revised  and  Rewritten.  32010. 

Cloth,  i.oo;   Pocket-book  style,  1.25 

PHARMACY. 

Hartley.  Medical  and  Pharmaceutical  Chemistry.  Third 
Edition.  Cloth,  300:  Leather,  3.50 

Coblentz.  Manual  of  Pharmacy.  Illustrated.  By  Virgil 
Coblentz.PH  D  ,  Professor  of  Theory  and  Practice  of  Pharmacy, 
College  of  Pnarraacy  of  City  of  New  York.  Octavo.  500  pages. 

Cloth.  4.00 

U.  S.  Pharmacopoeia,  1890,  7th  Revision. 
Cloth,  net,  2  50;  Sheep,  net,  3  oo.    (Add  27  cents  if  to  go  by  mail.) 

Sayre.  Organic  Materia  Medica  and  Pharmacognosy. 
543  Illustrations.  See  page  Q.  8vo.  Cloth,  4.50 

Stewart's  Compend  of  Pharmacy.  Based  upon  Remington's 
Text-book  of  Pharmacy.  Fifth  Edition,  Revised  in  accordance 
with  new  U.S  P.,  1890.  Cloth,  i.oo;  Interleaved  for  Notes,  1.25 

Robinson.  Latin  Grammar  of  Pharmacy  and  Medicine. 
By  H.  D.  Robinson,  PH.D.,  Professor  of  Latin  Language  and 
Literature,  University  of  Kansas,  Lawrence.  With  an  Intro- 
duction by  L.  E.  Sayre,  PH.G.,  Professor  of  Pharmacy  in,  and 
Dean  of.  the  Dept.  of  Pharmacy,  University  of  Kansas.  12010. 
Second  Edition,  Revised.  Cloth,  2.00 

SKIN  DISEASES. 

Crocker.  Diseases  of  the  Skin,  their  Description,  Pathology, 
Diagnosis,  and  Treatment,  with  Special  Reference  to  the  Skin 
Kniplions  of  Children.  By  H.  Radcliffe  Crocker,  P.R.C  p.,  Phy- 
sician for  Diseases  of  the  Skin  in  L'niversity  College  Hospital. 
Second  Edition.  Revised  and  Enlarged,  with  92  Wood-cuts. 

Cloth,  5.00 

Van  Harlingen  on  Skin  Diseases.  Third  Edition.  Enlarged 
and  Illustrated.  12010.  In  Preit. 

te  faffs  a  to  5  for  list  of  New  KantuUt. 


STUDENTS'   TEXT-BOOKS   AND  MANUALS.        13 

SURGERY  AND    BANDAGING. 

Moullin's  Surgery,  by  Hamilton.  600  Illustrations  (some 
colored),  200  of  which  are  original.  Second  Edition. 

Cloth,  net,  7.00;  Leather,  net,  8.00;  Half  Russia,  net,  9.00 
***  Complete  circulars,  with  sample  pages  and  Illustrations,  free 
upon  application. 

Jacobson.  Operations  in  Surgery.  A  Systematic  Handbook 
for  Physicians,  Students,  and  Hospital  Surgeons.  By  W.  H.  A. 
Jacobson,  B.A.  Oxon.,  F.R.C.S.  Eng. ;  Ass't  Surgeon  Guy's  Hos- 
pital ;  Surgeon  at  Royal  Hospital  for  Children  and  Women,  etc. 
199  Illustrations.  1006  pages.  8vo.  Cloth.  5.00;  Leather,  6.00 
Heath's  Minor  Surgery,  and  Bandaging.  Tenth  Edition.  158 
Illustrations.  62  Formulae,  and  Diet  Lists.  Cloth,  2.00 

Horwitz's    Compend    of    Surgery,    Minor    Surgery   and 
Bandaging,    Amputations,    Fractures,    Dislocations,  Surgical 
Diseases,  and  the  Latest  Antiseptic  Rules,  etc.,  with  Differential 
Diagnosis  and  Treatment.     By  ORVILLB  HORWITZ,  B.S.,  M.D., 
Demonstrator  of  Surgery ,  Jefferson  Medical  College.   $th  Edition. 
Enlarged  and  Rearranged.    Many  new  Illustrations  and  Formulae. 
i2mo.        Cloth,  i. oo  ;  Interleaved  for  the  addition  of  Notes,  1.25 
***  The  new  Section  on  Bandaging  and  Surgical  Dressings  con- 
sists  of  32   Pages  and  41   Illustrations.     Every  Bandage  of  any 
importance   is  figured.      This,  with    the  Section  on  Ligation  of 
Arteries,  forms  an  ample  Text-book  for  the  Surgical  Laboratory. 
Walsham.    Manual  of  Practical  Surgery.    Third  Edition. 
Bv  WM.  J.  WALSHAM,  M.D.,  F.R.C.S.,  Asst.  Surg.  to,  and  Dem- 
of'  Practical  Surg.  in,  St.  Bartholomew's  Hospital;  Surgeon  to 
Metropolitan   Free  Hospital,  London.      With  318   Engravings. 
Seepages.  Cloth,  3.00;  Leather,  3.50 

URINE,  URINARY   ORGANS,  ETC. 

Holland.  The  Urine,  Gastric  Contents,  Common  Poisons, 
and  The  Milk.  Chemical  and  Microscopical,  for  Laboratory 
Use.  Illustrated.  Fifth  Edition.  I2mo.  Interleaved. 

Cloth,  1.25 

Ralfe.  Kidney  Diseases  and  Urinary  Derangements.  42  Illus- 
trations. I2mo.  572  pages.  Cloth,  2.75 

Marshall  and  Smith.  On  the  Urine.  The  Chemical  Analysis  of 
the  Urine.  Colored  Plates.  I2mo.  Cloth,  i.oo 

Memminger.    Diagnosis  by  the  Urine.    Illus.      Cloth,  i.oo 

Tyson.  On  the  Urine.  A  Practical  Guide  to  the  Examination 
of  Urine.  With  Colored  Plates  and  Wood  Engravings.  Eighth 
Edition,  Enlarged.  i2mo.  Cloth,  1.50 

Van  Niiys,  Urine  Analysis.     Illus.  Cloth,  i.oo 

VENEREAL  DISEASES. 

Hill  and  Cooper.  Student's  Manual  of  Venereal  Diseases, 
with  Formulae.  Fourth  Edition.  I2mo.  Cloth,  i.oo 

ee  pages  14  and  15  for  list  of  f  Quiz-Compends  f 


PQUIZ-COMPENDS? 

The  Best  Compends  for  Students'  Use 
in  the  Quiz  Class,  and  when  Pre- 
paring for  Examinations. 

Compiled  in  accordance  with  the  latest  teachings  of  promi- 
nent Lecturers  and  the  most  popular  Text-books. 

They  form  a  most  complete,  practical,  and  exhaustive 
set  of  manuals,  containing  information  nowhere  else  col- 
lected in  such  a  condensed,  practical  shape.  Thoroughly 
up  to  the  times  in  every  respect,  containing  many  new 
prescriptions  and  formulae,  and  over  six  hundred  illustra- 
tions, many  of  which  have  been  drawn  and  engraved 
specially  for  this  series.  The  authors  have  had  large  ex- 
perience as  quiz-masters  and  attaches  of  colleges,  with 
exceptional  opportunities  for  noting  the  most  recent  ad- 
vances and  methods. 

Cloth,  each  $1.00.    Interleaved  for  Notes,  $1.25. 

No.  I.  HUMAN  ANATOMY,  "  Based  upon  Gray."  Fifth 
Enlarged  Edition,  including  Visceral  Anatomy,  formerly 
published  separately.  ID  Lithograph  Plates,  New 
Tables,  and  117  other  Illustrations.  By  SAMUEL  O.  L. 
POTTER,  M.A.,  M.D.,  M.R.C.P.  (Lend.),  late  A.  A.  Surgeon  U.  S. 
Army,  Professor  of  Practice,  Cooper  Medical  College,  San  Fran- 
cisco. 

Nos.  a  and  3.     PRACTICE   OF   MEDICINE.     Fifth  Edi- 
tion.    By  DANIBL  E.  HUGHES,  M.D.,  Demonstrator  of  Clinical 
Medicine  in  Jefferson  Medical  College,  Philadelphia.  In  two  pans. 
PART  I. — Continued,  Eruptive,  and  Periodical  Fevers,  Diseases 
of  the  Stomach,  Intestines,  Peritoneum,  Biliary  Passages,  Liver, 
Kidneys,  etc.  (including  Tests  for  Urine),  General  Diseases,  etc. 

PART  II. — Diseases  of  the  Respiratory  System  (including  Phy- 
sical Diagnosis),  Circulatory  System,  and  Nervous  System;  Dis- 
eases of  the  Blood,  etc. 

%*  These  little  books  can  be  regarded  as  a  full  set  of  notes  upon 
the  Practice  of  Medicine,  containing  the  Synonyms,  Definitions, 
Causes,  Symptoms,  Prognosis,  Diagnosis,  Treatment,  etc.,  of  each 
disease,  and  including  a  number  of  prescriptions  hitherto  unpub- 
lished. 

No.  4.  PHYSIOLOGY,  including  Embryology.  Seventh 
Edition.  By  ALBBRT  P.  BRUBAKBR,  M.D.,  Prof,  of  Physiology, 
Penn'a  College  of  Dental  Surgery  ;  Demonstrator  of  Physiology 
in  Jefferson  Medical  College,  Philadelphia.  Revised,  Enlarged, 
with  new  Illustrations. 

No.  5.  OBSTETRICS.  Illustrated.  Fifth  Edition.  By 
HENRY  G.  LANDIS,  M.D.  Edited  by  WILLIAM  H.  WELLS,  M.D., 
Assistant  Demonstrator  of  Clinical  Obstetrics,  Jefferson  College, 
Philadelphia.  New  Illustrations. 


BLAKISTON'S  ?  QUIZ-COMPENDS  ? 

No.  6.  MATERIA  MEDICA,  THERAPEUTICS,  AND 
PRESCRIPTION  WRITING.  Sixth  Revised  Edition, 
Based  upon  U.  S.  P.  1890.  With  especial  Reference  to  the 
Physiological  Action  of  Drugs,  and  a  complete  article  on  Pre- 
scription Writing,  including  many  unofHcinal  remedies.  By 
SAMUEL  O.  L.  POTTER,  M.A.,  M.D.,  M.R.C.P.  (Lond.).late  A.  A. 
Surg.  U.  S.  Army;  Prof,  of  Practice,  Cooper  Medical  College, 
San  Francisco.  Improved  and  Enlarged,  with  Index. 

No.  7.  GYN^COLOGY.  A  Compend  of  Diseases  of  Women. 
By  WM.  H.  WELLS,  M.D.,  Ass't  Demonstrator  of  Obstetrics, 
Jefferson  Medical  College,  Philadelphia.  Illustrated. 

No.  8.  DISEASES  OF  THE  EYE  AND  REFRACTION, 
including  Treatment  and  Surgery.  By  L.  WEBSTER  Fox,  M.D., 
Chief  Clinical  Assistant  Ophfhalmological  Dept.,  Jefferson  Med- 
ical College,  etc.,  and  GEO.  M.  GOULD,  M.D.  71  Illustrations,  39 
Formulae.  Second  Enlarged  and  improved  Edition.  Index. 

No.  9.  SURGERY,  Minor  Surgery  and  Bandaging.  Illus- 
trated. Fifth  Edition.  Including  Fractures,  Wounds, 
Dislocations,  Sprains,  Amputations,  and  other  operations;  Inflam- 
mation, Suppuration,  Ulcers,  Syphilis,  Tumors,  Shock,  etc. 
Diseases  of  the  Spine,  Ear,  Bladder,  Testicles,  Anus,  and 
other  Surgical  Diseases.  By  ORVILLE  HORWITZ,  A.M.,  M.D., 
Demonstrator  of  Surgery,  Jefferson  Medical  College.  Revised 
and  Enlarged.  98  Formulae  and  167  Illustrations. 

No.  10.  CHEMISTRY.  Fourth  Edition.  Inorganic  and 
Organic.  For  Medical  and  Dental  Students.  Including  Urinary 
Analysis  and  Medical  Chemistry.  By  HENRY  LKFFMANN,  M.D., 
Prof,  of  Chemistry  in  Penn'a  College  of  Dental  Surgery,  Phila. 
Fourth  Edition,  Revised  and  Rewritten,  with  Index. 

No.  ii.  PHARMACY.  Based  upon  "  Remington's  Text-book 
of  Pharmacy."  By  F.  E.  STEWART,  M.D. ,  PH. G.,  Quiz-Master 
at  Philadelphia  College  of  Pharmacy.  Fifth  Edition,  Revised. 

No.  la.  VETERINARY  ANATOMY  AND  PHYSIOL- 
OGY. 29  Illustrations.  By  WM.  R.  BALLOU,  M.D.,  Prof,  of 
Equine  Anatomy  at  N.  Y.  College  of  Veterinary  Surgeons. 

No.  13.  DENTAL  PATHOLOGY  AND  DENTAL  MEDI- 
CINE. Containing  all  the  most  noteworthy  points  of  interest 
to  the  Dental  student.  Second  Edition.  By  GEO.  W.  WARREN, 
D.D.S.,  Clinical  Chief,  Penn'a  College  of  Dental  Surgery,  Phila- 
delphia. Second  Edition,  Enlarged  and  Illustrated. 

No.  14.  DISEASES  OF  CHILDREN.  By  DR.  MARCUS  P. 
HATFIELD,  Prof,  of  Diseases  of  Children,  Chicago  Medical 
College.  Colored  Plate. 

No.  15.  GENERAL  PATHOLOGY  AND  MORBID 
ANATOMY.  By  H.  NEWBBRY  HALL,  M.  D.,  Professor  of 
Pathology  and  Medical  Chemistry  Post-Gradnate  School ;  Sur- 
geon Emergency  Hospital,  Chicago,  etc.  91  Illustrations. 

Bound  in  Cloth,  $1.    Interleaved,  for  the  Addition  of  Notes,  $1.25. 

fi@?"  No  series  of  books  are  so  complete  in  detail,  concise 
in  language,  or  so  well  printed  and  bound.  Each  one 
forms  a  complete  set  of  notes  upon  the  subject  under  con- 
sideration, 

Illustrated  Descriptive  Circular  Free. 


3O.OOO  COPIES 
Of  These  Books  Have  Already  Been  SoU. 

GOULD'S  STUDENT'S 

MEDICAL  DICTIONARY 

Based  on  Recent  Medical  Literature. 


Small  8vo,  Half  Morocco,  as  above,  with  Thumb  Index, .  .  £4.?$ 
Plain  Dark  Leather,  without  Thumb  Index, 3.25 


A  compact,  concise  Vocabulary,  including  all 
the  Words  and  Phrases  used  in  medicine,  with 
their  proper  Pronunciation  and  Definitions. 


"  One  pleasing  feature  of  the  book  is  that  the  reader  can  almost 
invariably  find  the  definition  under  the  word  he  looks  for,  without 
being  referred  from  one  place  to  another,  as  is  too  commonly  the 
case  in  medical  dictionaries.  The  tables  of  the  bacilli,  nucrococci, 
leucomaiines  and  ptomaines  are  excellent,  and  contain  a  large 
amount  of  information  in  a  limited  space.  The  anatomical  tables 
are  also  concise  and  clear.  .  .  .  We  should  unhesitatingly 
recommend  this  dictionary  to  our  readers,  feeling  sure  that  it  will 
prove  of  much  value  to  them."— American  Journal  of  Medical 
Science. 

JUST  PUBLISHED. 

GOULD'S    POCKET    DICTIONARY.     12,000 
Medical  Words  Pronounced  and  Defined. 
Leather,  gilt  edges,  JSi.oo;  with  Thumb  Index,  $1.25 


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